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DISEASES 



NOSE, THROAT AND EAR 



MEDICAL AND SUEGICAI 



BY 

WILLIAM LINCOLN BALLENGEE, M.D. 

PROFESSOR OF OTOLOGY, RHINOLOGY AND LARYNGOLOGY, COLLEGE OF PHYSICIANS AND SURGEONS, 

DEPARTMENT OF MEDICINE, UNIVERSITY OF ILLINOIS; FELLOW OF THE AMERICAN 

LARYNGOLOGICAL ASSOCIATION; FELLOW OF THE AMERICAN LARYNGOLOGICAL, 

RHINOLOGICAL AND OTOLOGICAL ASSOCIATION; FELLOW OF AMERICAN 

ACADEMY OF OPHTHALMOLOGY AND OTOLARYNGOLOGY, ETC. 



ILLUSTRATED WITH 471 ENGRAVINGS AND 16 PLATES 




LEA & FEBIGER 

PHILADELPHIA AND NEW YORK 

10 OS 



Two Copies rtecBtvju 

APR 2B 1908 


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Entered according to Act of Congress, in the year 1908, by 
LEA & FEBIGER, 
the Office of the Librarian of Congress at Washington. All rights reserved. 



PREFACE 



A NEW work, superadding itself to the already rich literature on the 
nose, throat, and ear, should justify its creation by some special features 
which may claim the attention of students and practitioners. Accord- 
ingly it may be said of the present volume, in the first place, that it 
includes the whole range of these three subjects, instead of dealing fully 
with the nose and throat, and only with the associated affections of the 
ear. It is no longer necessary to explain the advantages of considering 
these closely interrelated subjects together, since, obviously, they cannot 
be considered separately without missing most important connections. 
The relation of the eye to diseases of the sinuses is also introduced, 
though the significance of its relationship is not yet fully understood. 

Moreover, our knowledge of the inflammatory diseases of the nose 
and accessory sinuses, and of the throat and ear, has been increasing 
with such strides that the time seems to have arrived for presenting the 
subject on a new and higher plane. The causes of infection and inflam- 
mation of the cavities lined with mucous membranes are better under- 
stood, and it has accordingly become possible to give them in their true 
relation to the diseases. Instead of their mere enumeration, each has 
been discussed here with the purpose of showing its exact relation to the 
disease under consideration. The exciting causes are pathogenic bac- 
teria, while the predisposing causes are those extranasal and intranasal 
conditions which lower the resistance of the tissues. The numerous 
extranasal causes of infection and inflammation of the cavities of the 
nose and accessory sinuses have long been recognized. The intranasal 
causes of chronic inflammation of these cavities have not, however, been 
as well understood. The attempt has been made to show the effects of 
anatomical and pathological obstructions in the various portions of the 
nasal chambers upon chronic catarrhal inflammations of the nose, and 
upon chronic catarrhal and suppurative inflammations of the accessory 
sinuses. The advantage of this viewpoint is that it aft'ordsa more satis- 
factory explanation of the etiology and rationale of the treatment of 
infections and inflammatory diseases of all three regions. 



iv PREFACE 

The author has long beheved that surgical technique could be most 
clearly elucidated by describing each step of the various operations in 
numbered paragraphs, and by complementing them with suitable draw- 
ings. Nearly every operation is therefore illustrated, some with more 
than twenty drawings. About five hundred original drawings and 
plates have been thus used in the preparation of this work. The original 
sketches were made by the author, and were redrawn by Mr. James 
Kelly Parker, to whose intelligent cooperation much credit is due, 
and is gratefully acknowledged. An endeavor has been made to 
combine the advantages of a text-book and atlas, and, it is hoped, with 
a measurable degree of success. 

Tracheobronchoscopy and esophagoscopy have been brought to such 
a high degree of perfection, and the occasions for their employment 
are so numerous, that a fully illustrated chapter is devoted to their 
consideration. 

Before beginning this work, the author wrote to many of the leading 
specialists in the United States, England, France, Germany, Austria, 
Spain, Italy, Holland, Switzerland, Canada, and Russia, asking for 
reprints of their published articles. The response was most generous, 
and resulted in the accumulation of nearly three thousand monographs, 
which have been freely used in the preparation of this volume. With 
every wish to name each one who so liberally responded, it is obviously 
impracticable in a work of this character. The author has, however, 
endeavored to give due credit in the text for writings consulted. A debt 
of gratitude is also due to colleagues who have so graciously contril)uted 
to whatever of success this volume may attain. 

Grateful appreciation is also due to Dr. George F. Suker, Dr. Joseph 
C. Beck, and Dr. Mortimer Frank for their assistance in translations, 
and in the compilation of the material used in portions of the text, 
and also to Dr. Henrietta Gould and Miss INIary Regan for efficient 
attention to many minor but important details. 

Finally, to tlie publishers, with whom he has maintained most cordial 
r(>lations, the author expresses his thanks, not only for the physical 
appearance they have given to liis work, but also for many valuable 
aids and suggestions, which have both lightened and added confidence 
to his labors. 

W. L. B. 

103 State Strekt, Chicago. 



CONTENTS. 

PART I. 
THE NOSE AND ACCESSORY SINUSES. 

CHAPTER I. 

THE CLINICAL ANATOMY AND PHYSIOLOGY OF THE NOSE AND 

ACCESSORY SINUSES 17 

CHAPTER II. 

THE NOSE, THROAT, AND EAR IN RELATION TO GENERAL 

MEDICINE 29 

CHAPTER III. 
THE OFFICE EQUIPMENT 40 

CHAPTER IV. 

THE ETIOLOGY OF DEFORMITIES AND DEVIATIONS OF THE 

SEPTUM NASI 60 

CHAPTER V. 

THE CHOICE OF SEPTUM OPERATIONS. THE SURGICAL COR- 
RECTION OF OBSTRUCTR^E LESIONS OF THE SEPTUM . 71 

CHAPTER VI. 

THE ETIOLOGY OF INFLAMMATORY DISEASES OF THE NOSE 

AND ACCESSORY SINUSES 105 

CHAPTER VII. 

THE PRINCIPLES OF TREATMENT OF INFL.AMMATIONS. THE 
MODALITIES FOR PROMOTING THE REACTIONS OF IN- 
FLAMMATION 117 

CHAPTER VIII. 
THE INFL.VMMATORY DISEASES OF THE NOSE 130 

CHAPTER IX. 
THE I.NDlNIDrAL SINUSES 163 

CHAPTER X. 
GENERAL CONSIDKKA IIOXS IN REFERENCE TO THE SINUSES. 179 

CHAPIKI! XT. 
THE SURGERY OV THE ACCESSOIJY SLNTSES 201 



vi CONTENTS 

CHAPTER XII. 

NASAL NEUROSES. NASAL HYDRORRHEA. CEREBROSPINAL 

RHIXORRHEA 240 

CHAPTER XIII. 
NEOPLASMS OF THE NOSE 254 

CHAPTER XIV. 

EPISTAXIS (NASAL HEMORRHAGE). RHINOSCLEROMA. FURUN- 

CULOSIS. SCREW-WORMS 269 

CHAPTER XV. 
THE SURGICAL CORRECTION OF EXTERNAL NASAL DEFORMITY 277 

CHAPTER XVI. 
CHRONIC GRAXULOMATA OF THE NOSE, THROAT, AND EAR . 285 



PART 11. 
THE PHARYNX AND FAUCES. 

CHAPTER XVII. 
DISEASES OF THE EPIPHARYNX AND BASE OF THE TONGUE . 313 

CHAPTER XVIII. 
INFLAMMATORY DISEASES OF THE MESOPHARYNX AND FAUCES 334 

CHAPTER XIX. 
THE FUNCTIONAL NEUROSES OF THE PHARYNX 346 

CHAPTER XX. 
NEOPLASMS OF THE PHARYNX 350 

CHAPTER XXI, 
DISEASES OF THE FAUCES AND. TONSILS 360 

CHAPTER XXII. 
THE INFLAMMATORY DISEASES OF THE TONSIL 376 

CHAPTER XXIII. 
THE SURGERY OF THE TONSILS 393 

CHAPTER XXIV. 
NEOPLASMS OF THE TONSIL 415 



CONTENTS vii 

PART III. 
DISEASES OF THE LARYNX 

CHAPTER XXV. 
INFLAMMATORY DISEASES OF THE LARYNX AND EPIGLOTTIS . 421 

CHAPTER XXVI. 

PACHYDERMIA LARYNGIS. MALFORMATIONS AND DEFORMITIES. 
PROLAPSE OF THE VENTRICLES. STENOSIS. SUBGLOTTIC 
STENOSIS 475 

CHAPTER XXVII. 
NEUROSES OF THE LARYNX 482 

CHAPTER XXVIII. 
THE SINGING VOICE 499 

CHAPTER XXIX. 
DEFECTS OF SPEECH 510 

CHAPTER XXX. 
NEOPLASMS OF THF LARYNX 518 

CHAPTER XXXI. 

FOREIGN BODIES IN THE LARYNX, TRACHEA, BRONCHI, AND 

ESOPHAGUS 548 



PART IV. 
THE EAR. 

CHAPTER XXXIL 
THE CLINICAL ANATOMY AND PHYSIOLOGY OF THE EAR . . 567 

CHAPTER XXXIII. 
THE FUNCTIONAL TESTS OF HEARING 583 

CHAPTER XXXrV\ 
THE GENERAL ETIOLOGY OF DEFECTIVE HEARING .... 594 

CHAPTER XXXV. 

FOREIGN BODIES IN THE EAR. CERUMIXOUS PLUGS IN THE 

MEATUS 600 



viii COXTEXTS 

CHAPTER XXXVI. 

MALFORMATIONS AND NEOPLASMS OF THE AURICLE . . . .611 

CHAPTER XXX\TI. 

DISEASES OF THE AURICLE AND EXTERNAL MEATUS ... 621 

CHAPTER XXXVIII. 

MALFORMATIONS AND DISEASES OF THE MEMBRANA TYMPANI 637 

CHAPTER XXXIX. 

THE DISEASES OF THE EUSTACHIAN TUBES 651 

CHAPTER XL. 

THE PRINCIPLES AND METHODS OF TYMPANIC INFLATION . 659 

CHAPTER XLI. 

INFLAMMATORY DISEASES OF THE TYMPANUM 670 

CHAPTER XLII. 

HYPEROSTOSIS OF THE BONY CAPSULE OF THE LABYRINTH . 703 

CHAPTER XLIII. 

ACUTE AND CHRONIC SUPPURATIVE OTITIS MEDIA. CHOLES- 
TEATOMA 708 

CHAPTER XLIV. 

THE SEQUEL.E OF SUPPURATIVE OTITIS MEDIA, MASTOIDITIS, 
AND CHOLESTEATOMA. SUPPURATION OF THE LABY- 
RINTH 731 

CHAPTER XLX. 

PRINCIPLES OF TREATMENT AND GENERAL CONSIDERATIONS 

IN SUPPURATIVE OTITIS MEDIA 740 

CHAPTER XLVI. 

THE GENERAL PATHOLOGY OF OTITIS MEDIA AND MASTOIDITIS 754 

CHAPTER XL^'II. 

INTRACRANIAL AND JUGULAR PYOGENIC DISEASES OF OTITIC 

ORIGIN 759 

CHAPTER XLVIII. 
THE SURGERY OF THE TEMPORAL BONE 774 

CHAPTER XLIX. 
FACIAL PARALYSIS 841 

CHAPTER L. 

DISEASES OF THE PERCEPTION APPARATUS. AUDITORY NER^'E 

APPARATUS 848 

CHAPTER LI. 
I)EAF-MUTISM 874 



DISEASES OF NOSE, THROAT, AND EAR, 



PART I. 

THE NOSE AND ACCESSORY SINUSES. 



CHAPTER I. 

THE CLINICAL ANATOMY AND PHYSIOLOGY OF THE NOSE AND 
ACCESSORY SINUSES. 

THE NOSE. 

The Nasal Chambers.— The nose is divided, by the nasal septum, 
into two chambers, the right and the left. The nasal chambers are for 
respiratory, olfactory, phonatory, and gustatory purposes. The inspira- 
tory current passes upward from the vestibules to the middle and superior 
meatuses, and is thence deflected downward and backward by the 
middle turbinals and the roof of the nose to the choanse, and on into 
the epipharynx. The expiratory current is deflected from the vault 
of the epipharynx into the choanse, and thence forward through the 
middle and inferior meatuses to the vestibules of the nose. 

The practical clinical application of the foregoing facts lies in the 
different effects of stenosis in the inferior and in the superior portions 
of the nasal chambers. An obstructive deformity of the lower portion 
of the septum may interfere somewhat with the expiratory current, as 
it blocks the inferior meatus while the middle and superior meatuses 
are free, and the expiratory current, therefore, passes through the nasal 
chamber upon the obstructed side with but little or no impediment. 
The obstruction in the lower portion of the nasal chamber does not 
materially interfere with the inspiratory current, as its course is normally 
higher in the nasal passage. There are exceptions, however, to this 
rule. If, for example, the deformity of the septum extends well for- 
ward into the vestibule of the nose it will materially interfere with the 
respiratory current, as it blocks the entrance to the nose. 

The indications for the correction of an obstructive lesion of the 
inferior portion of the septum depend very largely upon whether or not 
2 



IS THE NOSE AND ACCESSORY SINUSES 

it blocks the vestibule of the nose. If it does, its correction is positively 
indicated; if it does not, the indications for its correction are not so clear. 
If, however, it impinges upon the inferior turbinal, it may produce 
a sense of "stuffiness," or of a foreign body in the nose, and cause 
the patient to "sniff and blow" in the effort to relieve the disagreeable 
sensation. It may, in addition to the foregoing, cause mechanical 
irritation of the mucous membrane of the inferior turbinal, and cause it 
to become engorged with blood, thereby increasing the obstruction of 
the inferior portion of the nasal chamber upon the affected side. 

When the obstructive lesion blocks the vestibule of the nose the 
entrance of the inspiratory current of air is materially interfered with. 
The descent of the diaphragm increases the air space in the lungs, and, 
according to a law of physics, the air from without tends to "rush 
in" to fill the vacuum thus created. The presence of the obstruction in 
the vestibule prevents its speedy entrance, and there is, therefore, 
a state of negative pressure in the nasal chamber — indeed, in both 
chambers, as their combined space is not sufficient to accommodate the 
required volume of air. The negative pressure or partial vacuum thus 
created results in a hyperemia of the mucous membrane of the nose and 
accessory sinuses. That is, the blood is attracted to the parts wherein 
there is a state of negative pressure. In addition to the hyperemia 
there is a greater or less transudation of serum into the loose submucous 
tissue. This condition is known as chronic rhinitis with turgescence. 
If the turgescence is perpetuated sufficiently long, true hypertrophy of 
the mucous membrane occurs. This is known as hypertrophic rhinitis. 

It appears, therefore, that obstructions located in the inferior and 
anterior portions of the nasal chambers are of considerable clinical 
importance, though not of as great importance as obstructive lesions 
located higher in the nose, as we shall attempt to show in the follow- 
ing paragraphs. 

When the upper portion of the nasal chamber is obstructed the 
path of the inspiratory current of air is blocked to a notable degree, and 
there is a sense of pressure through the upper portion of the nose. In 
addition to this the olfactory fissure is closed and the drainage of the 
secretions from the superior meatus and the accessory sinuses draining 
into it (the posterior ethmoidal and sphenoidal) is interfered with. The 
secretions are retained, undergo decomposition, and irritate the nuicous 
membrane in this region. Chronic inflammation results. The epithe- 
lium is lowered in vitality, and is, therefore, less able to perform its 
functions of elaborating the mucus of the normal secretion and of pro- 
pelling it to the choance by means of its cilipe. 

The irritation thus set up produces tissue proliferation or hyperplasia 
of the mucous membrane of the middle turbinal. This condition is 
known as hyperplastic rhinitis. 

The foregoing conditions are favorable for pathogenic infection; 
hence, suppurative inflammation of the mucous membrane of the nose 
and accessory sinuses may develop. This condition is known as sinuitis. 

It appears, therefore, that when the upper portions of the nasal chambers 



THE NOSE 19 

are obstructed, there is not only a disagreeable sense of pressure across 
the bridge of the nose, but inflammatory diseases of the accessory 
sinuses may arise. One who has seen many of these cases knows how 
difficult it often is to thoroughly eradicate the sinus disease when it 
is thoroughly established in several of the sinuses, hence the importance 
of recognizing the clinical importance of obstructive lesions in the region 
of the middle turbinated body. This region is elsewhere described as 
the "vicious circle" of the nose. 

The sinus labyrinth is so extensive, and much of it so inaccessible to 
actual inspection, that a complete effacement of morbid processes in 
them is often quite difficult except after the most complete exenteration 
of the sinuses, and especially of the ethmoidal sinuses. 

The Septum. — This subject is fully discussed in connection with the 
deformities and malformations of the septum. 

The Turbinated Bodies. — The turbinated bodies, three in number, 
are located upon the outer wall of the nasal chambers, and are known 
as the inferior, middle, and superior turbinated bodies. Only the 
inferior and middle are of clinical importance. These are characterized 
by the presence of venous plexuses in the submucous tissue of the 
membrane known as "swell bodies," or as the erectile tissue of the nose. 
The erectile tissue is chiefly distributed along the inferior border of the 
inferior turbinal, and on the posterior ends of the inferior and middle 
turbinals. Its function is supposed to be that of warming the inspired 
air and of regulating the amount of serous secretion. Either process is 
of vital importance to the lower respiratory tract. The lower respira- 
tory tract does not secrete enough moisture for physiological purposes 
(protective), nor is it capable of warming the inspired air sufficiently 
to bring it to the body temperature without injury to its mucous mem- 
brane. It is important that the heating and humidifying apparatus of 
the nose should be in good physiological condition. When, therefore, the 
vasomotor nerves regulating the erectile tissue are disturbed in their 
function, the preparation of the inspired air for the lower air tract is 
imperfectly performed. The lower air tract is exposed to the irritating 
influence of the inspired air, and irritation of the lining mucosa and of 
the endothelial cells lining the air vessels of the lungs may result in 
a bronchitis, while the transfusion of the gases, oxygen and carbon 
dioxide, may be disturbed in the air vesicles. The processes of tissue 
metabolism or the chemistry of nutrition are perverted. 

In addition to the foregoing conditions resulting from the disturbed 
functions of the "swell bodies," the patient may experience either a 
sense of "stuffiness" of the nose or of a foreign body, or the reverse, an 
unduly open nose. If, for instance, there is an anterior or vestibular 
()l)struction fi-om any cause, the negative pressure thus brought about 
causes an engorgement of the "swell bodies," with the resuhant dis- 
agreeable symptoms already described. This condition is known as 
rhinitis with turgescence. If, on the contrary, the patient is anemic, the 
swell bodies may become collapsed and the nasal chambers unduly 
patulous. This condition is known as I'ln'nilis with (■()II;ij)se of theerectile 



20 THE NOSE AND ACCESSORY SINUSES 

tissue. The turbinated bodies are of clinical interest, for the further 
reason that they divide the nasal chambers into three partial chambers 
or meatuses. The inferior meatus is the space between the floor of the 
nose and the inferior turbinal. The middle meatus is the space between 
the inferior and middle turbinals. The superior meatus is the space 
above the middle turbinal. The meatuses are of great clinical interest 
on account of the accessory nasal sinuses opening into them. 

The Meatuses. — ^^Phe inferior meatus is of clinical importance, as the 
nasal orifice of the tear duct opens in its anterior portion (Fig. 165), and 
because it is a part of the expiratory air tract. 

The Middle Meatus. — The middle meatus is of great clinical impor- 
tance because the frontal, anterior ethmoidal, and the maxillary sinuses 
open into it. The frontal and the anterior ethmoidal cells drain into the 
infundibulum in 50 per cent, of the cases. The bulla ethmoidalis and 
the cells in the middle turbinal (Fig. 140) do not drain into the infundib- 
ulum, but open directly into the middle meatus. The bulla is often 
quite large and bulges so much toward the septum that it encroaches 
upon the infundibulum, entirely obstructing it. It thereby interferes 
with the drainage of the frontal maxillary and the anterior ethmoidal 
cells. The cells opening into the middle meatus are referred to for 
convenience as Series I. 

When pus is present in the middle meatus it is significant of empyema 
of one or more of the cells comprising Series I, namely, the frontal 
sinus, the anterior ethmoidal, and the maxillary sinuses (antrum of 
Highmore). 

The Superior Meatus. — The superior meatus is of clinical interest 
because the posterior ethmoidal and the sphenoidal cells (Series II) 
open into it. This meatus cannot be directly inspected on account of 
its hidden position above the middle turbinal. It can, however, be 
examined with a probe. When pus flows into it from the posterior 
ethmoidal and sphenoidal sinuses, and the olfactory fissure is not com- 
pletely closed, it may be seen lying between the septum and the middle 
turbinal (the olfactory fissure). Pus in this region is, therefore, of 
great clinical value in making a differential diagnosis as to which series 
of sinuses is involved in the suppurative process. 

The superior meatus is of still further clinical interest because the 
terminal filaments of the olfactory nerve are distributed there. Formerly 
it was held that the olfactory nerve was distributed over the superior 
turbinal and the upper and median surfaces of the middle turbinal and 
the corresponding portion of the septum. Recent anatomists have found 
its area of distribution restricted to the superior turbinal and a corre- 
sjjondingly small area of the septum (Fig. 5). In some of the lower 
animals its distribution is over a much larger area, and in those with 
a very acute sense of smell, into the accessory nasal sinuses. 

The Sinuses' Residual Organs. — The nasal accessory sinuses in man 
are the residual remains of the olfactory organ, hence they have a low 
recuperative power after operations. I have repeatedly observed the 
slow and sometimes incomplete repair after operations even after the 



THE NOSE 21 

most thorough exenteration, especially of the ethmoidal cells. I attribute 
this to the fact that the structures in man have ceased to perform the 
function they were originally designed to do. Through long ages of 
retrogression the tissues have lost some of their vitality and do not 
regenerate with the same vigor that is manifested by structures still 
performing their functions. 

The Nerve Supply of the Nose.— The Sensory Nerves.— The sensory 
nerves of the nasal septum, the N. ethmoidalis anterioris and the 
N. nasopalatinus, send their filaments to the anterior and posterior por- 
tions of the septum, respectively. The N. ethmoidalis anterioris passes 
through the anterior portion of the cribriform plate (Fig. 1), thence for- 
ward and downward to the vestibule. The N. nasopalatinus extends 
forward and downward on the septum to the canalis incisivus, anas- 
tomoses with that of the other side and with the vessels of the mucous 
membrane of the hard palate. 




Nerve supply of the septum nasi, a, N. ethmoidalis anterioris; b, N. olfactorii; 
c, N. nasopalatinus; d, canalis incisivus. (After Spalteholz.) 

The sensory nerve supply of the outer walls of the nose is derived from 
the N. ethmoidalis anterioris and from branches of the ganglion spheno- 
palatinum. The N. ethmoidalis anterioris supplies the anterior portion 
of the lateral walls in front of the turbinated bodies, and the turbinated 
bodies are supplied by branches of the sphenopalatine ganglion (Fig. 2). 
The hard and soft palates are also supplied from this ganglion. These 
anatomical facts may be utilized in injecting cocaine for anesthetic 
purposes (Killian) and in injecting alcohol in the treatment of hy})cr- 
esthetic rhinitis (O. J. Stein). 

Vasomotor branches are also supplied to the vessels of the jnucous 
membrane and erectile tissue of the turbinated bodies from the ganglion 
sphenopalatinum, and is under the control of the vasomotor centres of the 
medulla, when there is probably a connection with the nuclei of the vagus 
through association fibers (Watson Williams). 



22 THE XOSE AXD ACCESSORY SIXUSES 

The distribution of the accessory nerves over the septum and the outer 
walls of the nose, and especially the branches from the sphenopalatine 
ganglion over the turbinals, at once suggests the reason for the sensitive- 
ness of these areas when the mucous membrane is inflamed, or is so 
swollen that it impinges against the septum. It also suggests the reflex 
phenomena, as asthma, often observed when there is inflammation 
or other disease in these regions. The association fibers, referred to 
above, connecting the sphenopalatine ganglion with the vagus establish a 
physiological relationship between the upper and the lower respiratory 
tracts, hence the asthma of nasal origin. I have repeatedly seen cases 
in which the asthma promptly disappeared after the removal of nasal 
polypi, or after an exenteration of the ethmoidal labyrinth for sinuitis. 
The irritation of the terminal filaments of the turbinal branches from 




Nen'es of the lateral wall of the nose, a, ganglion sphenopalatiniun; b, rami nasales pos- 
teriores superiores laterales; c, rami nasales posteriores inferiores laterales; d, Nn. palatini; e, 
Nn. olfaetorii; /, rami nasales interni, N. ethmoidalis anteriores. (After Spalteliolz.) 



the sphenopalatine ganglion was thus removed, and the reflex stimulus 
through the ganglion to the vagus and thence to the bronchial muscles 
ceased to be given off; hence the bronchial spasm (asthma) was cured. 

The vascular engorgement present in chronic rhinitis with turgescence 
is due to a paresis of the vasomotor constrictor muscles supplied by the 
branches of the sphenopalatine ganglion. The paresis may be due to 
negative air pressure in the nasal chambers, whereby the vessels are 
overcharged with blood which "rushes in to fill the partial vacuum," or 
it may be due to the presence of toxic material in the blood, or to local 
morbid cliaiigcs in the swell bodies. 

The Olfactory Nerve. — The olfactory nerve descends through the lamina 
cribrosa (cribriform })late) from the under surface of the olfactory bulb 
and is distributed in the mucous membrane covering the upper portion 



THE NOSE 23 

of the superior turbinal and a corresponding portion of the septum 
(Figs. 1, 2 and 5). Formerly it was thought that the distribution of 
the olfactory nerve in man was over a much more extensive area, the 
upper and median surfaces of the middle turbinal and a corresponding- 
area of the septum being included in the area of distribution. In 
many of the lower animals the nerve has a wider distribution; the sinuses 
communicating more freely with the nasal chambers are utilized for 
the spread of the terminal olfactory nerve filaments. In man they are 
the residual remains of the organ of smell, and only communicate with 
the nasal cavities through small ostei or cell openings, as they are no 
longer needed for olfaction. 

Inasmuch as the sinuses are the residual remains of the olfactory 
organs, D. Braden Kyle believes that they should not be needlessly 
opened by operative procedures and thus exposed to the irritating action 
of the inspired air, to which they are unaccustomed. He cites the 
uncomfortable sensations produced by the greater column of air sweeping 
through them after an exenteration of their walls, as an evidence of the 
possible harmful effects following an operation which opens the sinuses, 
so that there is free communication between them and the chambers 
of the nose. His point is well taken. The sinuses should not be need- 
lessly attacked, as local treatment and probing will in many cases 
afford relief to the symptoms, if not cure the disease. 

On the other hand, I have seen many cases in which the disagreeable 
sensations, caused by admitting a larger volume of air into the opened 
sinuses, disappear after a few weeks, the sinus disease being entirely 
eradicated. In some cases a choice must be made between the possible 
evil consequences of the disease and the evil consequences attending 
the cure of the disease. 

To return to the olfactory nerve. It is obvious that, if the middle 
turbinal and the septum are in apposition, the inspired air does not 
reach the olfactory region, hence there is anosmia or loss of smell. It 
follows that if the obstruction to the olfactory fissure is overcome, 
either by the removal of the middle turbinal or by the correction of 
the deviation of the septum, air is admitted to the olfactory region and 
the sense of smell is restored, provided the nerve has not undergone 
degeneration. 

Inasmuch as the distribution of the olfactory nerve is limited to the 
superior turbinal and the corresponding portion of the septum, the 
middle turbinal and the ethmoidal cells may be removed in their entirety 
without interfering with its distribution. In such operations the superior 
turbinal should l)e left intact in so far as it is compatible with a complete 
exenteration of the ethmoifhxl cells. 

The Blood Supply of the Nose. — The middle meningeal artery 
gives olf the spli('iioj)alatiiie branch, which, when it reaches the posterior 
portion of the lateral walls of the nose, subdivides into the lateral pos- 
terior nasal arteries. Tliese are distributed over the middle and inferior 
turbinals and in the middle and inferior meatuses. The superior tur- 
binal and the anterior portion of the outer walls of the nasal chambers 



24 



THE XOSE AXD ACCESSORY SIXUSES 



are supplied by the posterior etlimoidal and the anterior ethmoidal 
arteries, respectively (Fig. 3). 

As the posterior lateral nasal arteries are of considerable size, it is to 




The arterial supply of the lateral wall of the nose, a, A. meningea anterior; b, A. ethmoidalis 
anterior; c, A. etlimoidalis posterior; d, Aa. nasales posteriores laterales; e, A. sphenopalatina; 
f, Aa. palatinsD major et minores. 




The aiterial supply of the septum nasi, a, A. ethmoidalis anterior; b, A. ethmoidalis posterior; 
c, A. nasales posteriores septi; d, anastomosis with the A. palatina major. (After Spalteholz.) 



THE PHYSIOLOGY OF THE NOSE 25 

be expected that the removal of either the middle or inferior turbinated 
bodies may be attended by considerable hemorrhage. As a matter of 
fact, the removal of the middle turbinal is usually followed by more or 
less bleeding for twenty-four hours. There is a free anastomosis be- 
tween the lateral nasal arteries and the anterior ethmoidal artery, hence, 
after the removal of a turbinated body the bleeding may come from 
both sources though but one artery is injured. 

The septum is supplied by the A. nasales posteriores septi, a branch 
of the A. sphenopalatina, through the foramen sphenopalatinum. It 
has three main branches : one supplying the posterior, another the inferior, 
and the other the middle and posterior portions of the septum. 

The A. ethmoidalis anterior and the A. ethmoidalis posterior are 
distributed to the anterior and the superior portions of the septum 
(Fig. 4). Severe hemorrhage occasionally attends or follows operations 
upon the septum, especially when the operative field includes the middle 
branch of the A. nasales posteriores septi. A nasal douche of iced 
normal salt solution will often check the bleeding, though in some cases 
it becomes necessary to introduce a nasal tampon. I know of one case 
in which the bleeding continued at intervals for several weeks, with an 
ultimate fatal issue. Such instances are rare, however, and should not 
materially affect the question of operations upon the septum. 

The question of tamponing the nasal chambers after operations should 
be briefly considered in this connection. As the nose is a part of the 
breathway and is constantly invaded by pathogenic bacteria, it is of 
the greatest importance that free drainage and ventilation be constantly 
maintained, as otherwise the growth of the pathogenic bacteria may be 
encouraged. I believe that many of the secondary hemorrhages occur- 
ing after operations are due to local sepsis affecting the blood clot in 
the severed arteries. The septic clot breaks down, the blood pressure 
dislodges it, and hemorrhage occurs. A nasal tampon should only be 
used after operations when the indications are positive, and never as a 
routine practice. 

THE PHYSIOLOGY OF THE NOSE. 

The functions of the nose are olfactory, phonatory, respiratory, and 
gustatory. The gustatory function in man is probably of least impor- 
tance, the olfactory of secondary importance, the phonatory of tertiary 
importance, while the respiratory function is of the greatest importance. 

The Sense of Smell. — The olfactory function, or the sense of smell, 
is presided over by the upper portion of the nasal chambers, the olfactory 
nerve (Fig. 5) being distrilmted over the attic of the nose as far down- 
ward as the upper margin of the middle turbinated body and on the 
septum over a corresponding area. A knowledge of the area of dis- 
tribution of this nerve is of practical importance in the diagnosis, 
prognosis, and treatment of certain diseases of the nose. If there is 
anosmia, or loss of the sense of smell, the question arises as to whether 
the impairment is due to a degenerative change in the nerve itself, or 



26 



THE XOSE AXD ACCESSORY SIXUSES 



to an obstruction to the entrance of the odoriferous particles or emana- 
tions to the terminal cells of the olfactory nerve. If, upon examination, 
the middle turbinated body is resting ajrainst the septum, the removal 
of a portion of the middle turbinated body, or the correction of a devia- 
tion of the u])per portion of the septum, may restore the sense of smell. 
As the normal inspiratory breathway throutjh the nose includes the 
space above the middle turi)inated body, it is apparent that an obstruction 
of the type just mentioned would prevent the odoriferous particles or 
emanations from coming in contact with the olfactory area of the nose 
during the act of insj)iration. If, on the other hand, the examination 
shows the results of a long-continued suppurative process in the posterior 
ethmoidal cells, or an atrophic condition of the mucous membrane in 

the attic, with no obstructive lesion 
to prevent the inspired air enter- 
ing, the anosmia may be due to 
degenerative changes in the termi- 
nal epithelial cells of the olfactory 
nerve. 

The lesions may, however, be 
intracranial, in which case there 
may be no evidence of either an 
obstructive lesion or of degener- 
ative changes in the attic of the 
nose. 

The loss of the sense of smell, 
while not comparable to the loss 
of the nasal respiratory function, 
is, nevertheless, attended by con- 
siderable inconvenience. The 
pleasure experienced by the re- 
cognition of certain odors is 
longed for by those affected by 
anosmia. More than this, they 
have lost one of the senses where- 
by they are protected from harm 
by certain substances, as ammo- 
nia, etc. By its aid wc are warned of the near approach to decaying 
matter, or other foul-smelling and unsanitary substances. In the lower 
animals the sense of smell is of much greater utility in seeking food and 
in detecting the apj)n)ach of hunters and animals intent upon their 
destruction. 

Phonation. — 'I'lic ])art j)layed by the nose in the production of the 
speaking and singing voice is so great that Jeane de Keske has said 
that the more he studies the voice the more he is convinced that it is a 
question of the nose. I have often noted that popular public speakers 
have well-developed nasal resonance, while speakers otherwise gifted 
had difficulty in holding the attention of their audiences. While the 
initial tone is produced by the vibrations of the vocal cords, the voice 




Sliowing the area of distribution of the olfac- 
tory terminal nerve cells in the human nose. The 
triangular flap is the septum turned upward; 
tlie area of distribution is limited to the region 
of the superior turbinal, and a corresponding 
area of the septum of the middle turbinal re- 
ceiving few or no olfactory cells. 



THE PHYSIOLOGY OF THE NOSE 27 

is decidedly unpleasant and unmusical if it is not rich in overtones from 
the resonance chambers of the nose, throat, and chest. (See The Singing 
J^oice.) The nasal chambers and accessory cavities are of prime im- 
portance in voice production, and any obstruction from swelling of the 
mucous membrane, deflection, or other lesions of the septum so mate- 
rially alters the quality of the voice as to make it disagreeable and 
inartistic. A knowledge, therefore, of the phonatory functions of the 
nose is of practical importance, as the removal of the lesions which 
impair this function will convert an inartistic into an artistic, an un- 
pleasant into a pleasant, a comparatively useless into a useless voice. 

Nasal Respiration. — As before stated, the respiratory functions of 
the nose are its most important ones. The nasal chambers are more 
than mere tubes through which air is drawn into the lungs; they pro- 
duce certain changes in the air which prepare the air vesicles of the 
lungs so that they will permit of the normal transfusion of oxygen and 
carbon dioxide. The respiratory functions of the nose are threefold, 
namely: (a) to temper, (6) to humidify, and (c) to filter the inspired air. 

Experiments have demonstrated that no matter what the temperature 
of the air may be before it is inhaled, it is raised or lowered, as the case 
may be, to near the body temperature. The delicate structures of the 
deeper respiratory tract are thereby protected against the great varia- 
tions and extremes of temperature. 

It has also been shown that the air in passing through the nasal 
chambers receives moisture from the nasal mucous membrane. The 
mucosa of the lower respiratory tract and the epithelial walls of the air 
vesicles of the lungs are thus protected from the varying humidity of 
the atmosphere in which we live. In passing through the nose the air 
is raised (usually) in temperature, thus expanding it and increasing its 
capacity to absorb moisture. The swell bodies or erectile tissue of the 
nose, and the serum secreting glands of the nasal mucosa, give off moist- 
ure, which is rapidly taken up by the expanded air and carried to the 
lower respiratory tract, where the serum secreting organs are much 
less developed. It has been estimated that approximately one pint of 
serum is thus transferred from the nasal cavities to the lower respiratory 
tract in twenty-four hours. 

The part of the nasal structures chiefly concerned in the secretion of 
the serum is generally credited to the swell bodies or erectile tissue, 
located chiefly along the free border of the inferior turbinated bodies, 
and on the posterior ends of the middle and inferior turbinated bodies. 
It is these latter portions that sometimes become enlarged and form 
the so-called mulberry hypertrophies. It is probable that the mucous 
glands also secrete some of the serum. The swell bodies are imder 
the control of the vasomotor nervous system, which, under normal 
conditions, regulates the supply of moisture to meet the demands. If 
the air is dry the swell bodies enlarge and become just active enough to 
fully saturate the expanded air in the nose; whereas, if the atmosphere 
is humid they are less active. When there are obstructive lesions, or 
catarrhal inflammation is present, the swell bodies and glands do not 



28 THE NOSE AXD ACCESSORY SIXUSES 

respond normally to the atmospheric conditions, hence the air is not 
properly humidified in its passage tlirough the nose. The treatment of 
these conditions should, therefore, be so directed as to restore the swell 
bodies and glands to their normal activity. In order to do this it may be 
necessary to give stability to the vasomotor nervous system by judicious 
bathing, outdoor exercise, etc. In addition, local massage of the mucous 
membrane and other treatment may be necessary. Surgical interference 
should always respect the location of the swell bodies, care l^eing exer- 
cised to avoid their destruction, except in those cases in which they have 
already lost their function beyond hope of restoration. The surgery 
of the middle turbinated body may be practised with much greater 
freedom, because it does not have much to do with the respiratory func- 
tions of the nose. The inferior turbinated body, however, should be 
attacked surgically only when its secreting function is largely destroyed, 
or wdien it is so enlarged by hypertrophic or hyperplastic changes that 
it obstructs nasal respiration. 

That the nose is a filter is made evident upon inspection of the secre- 
tions, and the vibrissee of the vestibule, as they are loaded with dirt. 
The vibrissse guarding the atrium of the nostrils act as a coarse filter, 
the larger particles lodging on them, the smaller ones entering the nasal 
cavities, where they are caught upon the irregular surface of the moist 
mucous membrane. Tlie lower air tract is thus protected from the 
irritation which would otherwise result. 

The Gustatory Function of the Nose. — The real gustatory or 
taste sense (sweet, soiu-, acid, bitter, and salt) is supplied by the dis- 
tribution of the glossopharyngeal and the fifth nerves to the fauces and 
the base of the tongue, whereas, the delicate flavors which give so much 
pleasure to the consumption of foods and drinks are appreciated through 
the olfactory nerve. If the nostrils are closed and the eyes covered, it 
is almost impossible to distinguish between coffee and water of the 
same temperature, as the aromatic flavor cannot be appreciated by the 
nose when closed. 

Summary: The functions of the nose are fourfold, namely: 

1. Olfactory, residing in the attic of the nose. 

2. Phonatory, enriching the voice by overtones. 

3. Respiratory. 

(a) The air is warmed or tempered to or near the body temperature 
in passing through the nose, thereby preventing shock and irritation 
to the mucosa and air vesicles of the lower respiratory tract. 

(/>) The air is expanded by the warmth of the nasal chambers, and 
its capacity to absorb the moisture thrown off by the swell bodies and 
mucous glands is increased. The mucosa and air vesicles are thus 
moistened, or, at least, their moisture is not absorbed (the air being 
already saturated in its passage through the nose), and irritation is 
prevented. The nose keeps the inspired air in a state of saturation. 

(c) The air is filtered in its passage through the nose by the vibrissae 
and the moist mucous membrane. The irritation to the mucosa and 
air vesicles which would otherwise occur is thus prevented. 

4. The gustatory (olfactory) sense complements the sense of taste. 



CHAPTER 11. 

THE NOSE, THROAT, AND EAR IN RELATION TO GENERAL 
MEDICINE. 

The writings of William Meyer, of Copenhagen, William Daly, of 
Pittsburg, and E. P. Friedreich, of Leipsic, have given a breadth to 
rhinology, laryngology, and otology they did not have in the days when 
the practice along these lines was regarded as a "specialty." With 
this broader view they are now regarded as the pursuit of the practice 
of general medicine and surgery, with special reference to the diagnosis 
and treatment of diseases in general, and those of the nose, throat, and 
ear in particular. 

A proper comprehension of the relation of the nose, throat, and ear 
to general medicine and surgery will be facilitated by a brief analysis 
of the interdependence and coordination of the various organs and 
parts of the body. 

ELEMENTARY FACTS. 

(a) The Breathway. — The upper respiratory tract is the channel in 
which the air is prepared for the interchange of gases which takes place 
in the air vesicles of the lungs. The nose is specially concerned in the 
process of humidifying, warming, and filtering the inspired air, and it 
is obvious that any disease or obstruction that interferes with these physio- 
logical processes will affect the transfusion of gases through the capillary 
walls of the air vesicles. The absorption of oxygen by and the elimina- 
tion of carbon dioxide from the blood will not occur in normal ratio. 
The blood will be deficient in oxygen and surcharged with carbon dioxide. 
As oxygen is essential to the processes of assimilation and nutrition, its 
lessened quantity in the blood gives rise to certain disturbed conditions 
of the digestive, the assimilative, and the nutritive functions. The 
presence of an excess of carbon dioxide also adds to these disturbances. 
It is well known that the excessive accumulation of carbon dioxide in 
the blood acts as a poison to the leukocytes, thus interfering with their 
functional activity. A normal amount of carbon dioxide in the blood 
favors the assimilative and the nutritive process, and it is only after 
a greatly increased amount of it is present that there are marked dis- 
turbances. It not only interferes with the activity of the leukocytes, but 
also with other cellular structures of the body as well. The combined 
effect, therefore, of an increased amount of carbon dioxide, and a dimin- 
ished quantity of oxygen in the blood is to produce general anenn'a, in(h- 
gestion, malassimilation, and malnutrition. 



30 THE XOSE AXD ACCESSORY SINUSES 

The xantliin group of toxins, indiKlinij; indican, are thrown into the 
circulation and give rise to certain nervous phenomena, as restlessness, 
peevishness, headache, mental depression, aj)rosexia, and a general feel- 
ing of malaise. 

The digestive disturhances are still further increased by the infected 
secretions from the epi])harvnx and the tonsils. Putrefactive as well 
as pathogenic bacteria are swallowed with the secretions from the nose 
and throat, and give rise to Avhat is connnonly known as chronic dys- 
pepsia or indigestion. It is probable that the putrefactive germs are 
more potent in this connection than the streptococci and the staphy- 
lococci. The contlitions of the nose and throat which most commonly 
give rise to this kind of discharge are nasal stenosis, atrophic rhinitis, 
chronic rhinitis, sinuitis, epipharyngeal catarrh, and chronic follicular 
tonsillitis. 

There are certain conditions of the stomach and of the intestinal 
tract which affect the mucous membrane of the upper respiratory tract. 
If, for example, there is chronic indigestion, there is also malassimilation 
and faulty metabolism. The imperfect products of indigestion are im- 
perfectly oxidized and are thrown into the circulation, where they irritate 
the mucous membrane of the nose, as well as the vasomotor nerves, 
thus causing local congestion and overnutrition. The secretions of 
the glands of the mucous membrane of the upper respiratory tract are 
also thereby modified, thus predisposing to, or at least intensifying, 
the catarrhal disease present. In the same way hyperacidity and sub- 
acidity of the stomach may irritate the mucosa of the nose and throat. 
One of the most potent influences exerted by the products of indigestion 
is through the reflex nervous system, pharyngitis, hypersensitiveness, 
sneezing, etc., being the direct expressions of this condition. 

In atony of the stomach there is a putrefactive formation of gases, 
which act reflexly and through the circulatory system on the mucous 
membrane of the upper respiratory tract and cause phenomena quite 
similar to those just mentioned. Another condition which is quite similar 
in many respects to the foregoing is that which occurs in gout or 
lithemia. In connection with this (hsease the larynx and the pharynx 
are particularly afl'ected. In the pharynx there may be an itching 
behind the pillars of the fauces, associated with a similar irritation in 
the external meatus of the ear. Some observers regard these signs as 
characteristic of gout. 

When such symptoms apj)car, the administration of calomel and the 
bicarbonate of soda, followed in twelve hours by a saline i)urge, will 
give marked relief. After this it is well to administer teaspoouful doses 
of the phosphate of soda two or three times daily for a few weeks. 

Vomiting and eructation of gases from the stomach exert an irritating 
effect upon tlie nuicous membrane of the pharynx, the nasopharynx, 
and the nose, 'ilie irritation is due to biochemical as well as mechanical 
causes. Catarrhal iuflannnation in the epipharynx is thus perpetuated 
and may finally extend to the Eustachian tube and the middle ear, thus 
giving rise to tinnitus and deafness. 



ELEMENTARY FACTS 31 

(6) Intimate Relation between Organs. — All the organs of the body 
are more or less intimately connected by the vascular, the lymphatic, 
and the nervous systems, hence disturbances in one more or less affect 
the others. The bloodvessels and the lymph channels carry toxic and 
infective material to all the organs of the body, including the nose, 
throat, and ear, and thus influence the functions and the pathological 
processes present in these organs. While the data considered under 
this subject somewhat overlap those considered under (a), it is well, 
nevertheless, to emphasize certain features more prominently in this 
connection. 

Anemia is a condition of the blood due to various causes, and often 
gives rise to collapse of the erectile tissue of the nose. This is usually 
spoken of as "rhinitis with collapse of the turbinated bodies." While 
rhinitis with collapse is not of great importance, its presence is, never- 
theless, a source of information to the examining physician. When, 
for example, upon examination of the interior of the nose the inferior 
turbinated membrane is found tightly collapsed over the bony framework 
which supports it, the mucous membrane being comparatively dry and 
with no crusts distributed over it, it should lead at once to a suspicion 
that general anemia is present. It is bad practice to limit the treatment 
to the local nasal condition, as this will disappear under appropriate 
treatment for the anemia. 

On the other hand, another condition of the nasal mucous membrane 
which may cause anemia instead of being a result of it, as related in the 
preceding paragraph, is atrophic rhinitis. It is characterized by anemia, 
which is probably due to the absorption of toxic material from the nose, 
and to the loss of the respiratory functions of the nose. 

If the lymphatic vessels are charged with infective material, which 
is finally transferred to the bloodvessels and the tissues of the entire 
body, a state of general toxemia is induced, the nose, throat, and ear 
being brought more or less under the influence of the disturbed conditions 
in the lymphatic circulation. On the other hand, one of the commonest 
clinical pictures is that wherein the lymphatic glands are enlarged by 
suppurative diseases of the ear, nose, and throat. This subject is 
discussed more fully in the chapter on the Clinical Anatomy of the 
Tonsils. I wish, however, to emphasize the influence of suppurative 
diseases of the ear upon the lymphatic glands of the neck. As the ear 
is more intimately connected with the lymphatic glands of the posterior 
triangle of the neck, it is to the glands in this region that we should 
look for enlargement in inflammatory disease of this organ. 

The close approximation of the mucous membrane of the ear to the 
contents of the cranial cavity may also give rise to serious consequences 
by the conveyance of infective material thereto. Brain abscess, menin- 
gitis, septic throm})ophlebitis, etc., may thus be caused, although the 
usual channel of invasion is through the necrotic area in the tegmen 
tympani or the tegmen antri. 

The nervous system, when disturbed in its function, necessarily 
influences the upper respiratory tract, as well as other parts of the body. 



32 THE NOSE AND ACCESSORY SINUSES 

"We may thus liavc vasomotor rhinitis and asthma, as well as certain 
functional disturbances of the ear and the larynx. 

Hysteria probably comes under this heading, and while it is not demon- 
strable histologically, it has, nevertheless, a histological basis. Hysteria 
of the nose, throat, and ear, as in other parts of the body, is characterized 
l)y the disturbance of those functions which are more particularly under 
the control of the mind, the involuntary functions not being affected. In 
the larynx, for instance, the normal respiratory movements are not dis- 
turbed, as they are involuntary; whereas the movements of the larynx 
which are concerned in the production of speech, being under the con- 
trol of the mind, are voluntary, and are affected. 

Hay fever, laryngeal cough, sneezing, bronchial asthma, anesthesia 
and hyperesthesia of the mucous membrane of the ear, nose, and throat 
are reflex phenomena, which may result from the irritation of the 
nervous system by the toxic material in the circulation. 

Another very important disease generally regarded as due to infection 
of the blood is rheumatic fever, or acute articular rheumatism. The 
gateway of infection is often through the tonsils, or, at least, through 
the Waldeyer's ring. The throat symptoms of this disease are a red- 
dened pharynx, with a defined or circumscribed inflammation of the 
larynx, redness and swelling in the arytenoid region, and sometimes 
fixation of the arytenoid cartilages. Pain and difficulty in phonation 
and deglutition are also present in rheumatic fever. The physician 
should not only look upon the tonsils as the portals of infection, but he 
should look into the pharjmx and the larynx for the symptoms of the 
disease itself. Acute rheumatic fever also gives rise to certain symp- 
toms which are not commonly recognized. For instance, it may cause 
nose-bleed in children, and in some cases is undoubtedly the cause of 
chorea. 

Malaria is another disease affecting the blood which gives rise to 
certain diseases or symptoms in the ear, nose, and throat. IMastoid 
pain, and, indeed, mastoid suppuration, has been observed in which the 
malarial element was prominent. In view of some recent observations, 
it may be questioned, however, whether these cases were distinctly mala- 
rial in their origin. We know now that there are certain septic conditions 
which give rise to symptoms so nearly like those due to the plasmodium 
of malaria that it may be questioned whether these cases were truly 
malarial, or whether they were septic. It is known, however, that the 
n)alarial poison may cause nasal hydrorrhea and vasomotor rhinitis. 

The bloodvessels and lymph vessels are channels of communication 
between the throat and the appendix. In certain cases of appendicitis 
it has been shown that streptococcus infection was present both in the 
throat and in the appendix. Another possible source of communication 
in these cases is through the alimentary tract. 

{(') The Digestive Tract.— Tlie digestive tract, which prepares the 
food for tissue building, is affected by the putrefactive and the patho- 
genic microorganisms from the nose, throat, and ear. The primary 
treatment should be addressed to the relief of the diseased conditions of 



ELEMENTARY FACTS 33 

the upper respiratory tract, rather than to the stomach and the intestines. 
The presence of dyspepsia, or other functional disturbances of the 
stomach and the intestines, should lead to the examination of the nose 
and throat, with special reference to the discharges from them, which 
may be swallowed by the patient. On the other hand, if there is an irri- 
table state of the nasal, pharyngeal, and laryngeal mucous membranes, 
which is not explained by any local source of irritation, careful attention 
should be given to the condition of the stomach and the intestines, or to 
the organs of digestion and assimilation in general, with a view to deter- 
mining whether they are properly performing their functions. If they 
are not, the nutritive properties of the food are thrown into the circu- 
lation imperfectly or insufficiently prepared for their purposes. The 
irritation thus carried to the nasal mucous membrane and to the nerves 
supplying it may be the chief cause of the local disturbances. It is 
obvious that under these circumstances the treatment should be addressed 
to the correction of the disorders of the digestive tract, rather than to 
the nose, throat, and ear. 

(d) Excretory Organs. — The function of the excretory organs is to 
throw off the refuse material formed during the processes of nutrition. 
The refuse consists not only of the material not needed for the nutrition 
of the body, but also of the toxic material and the half-way products 
of oxygenation already referred to. Hence, any impairment of the 
functions of these organs results in an excess of toxic material in the 
blood and the lymphatic vessels, thereby causing congestion, irritation, 
hypertrophy, hyperplasia, or altered secretions in the upper respiratory 
tract. This feature of the subject is intimately associated with those in 
the preceding paragraphs. Nevertheless, it has its place in this con- 
nection, and should be considered apart from them. 

The skin and the kidneys being the chief excretory organs of the body, 
our attention will be given largely to their consideration. We will 
dismiss the skin with a brief reference to the fact that eczema, lupus, 
etc., affecting other portions of the body, may also involve the external 
nose and the external ear. Or, the pathogenic processes may begin 
with the skin of the nose or the external ear, and extend to other parts 
of the body. We will also mention incidentally that erysipelas of the 
nose may involve the nasal mucous membrane, and that erysipelas of 
the skin over the mastoid process may extend to the middle ear and 
the mastoid cells, or even to the cranial cavity through the lymphatics 
and the bloodvessels of this region. 

The kidneys, however, are the excretory organs which chiefly interest 
us in this connection. Bright's disease may manifest its earliest symp- 
toms in the mucous membrane of the throat. The throat symptom 
complained of is dryness. This same symptom may also be present in 
diabetes. Diabetes is mentioned here not because it is a disease of 
the kidneys, but because its chief symptom is to be found in the examina- 
tion of the excretions from the kidneys. 

When a patient complains of persistent dryness of the pharynx his 
urine should be examined for albumin, casts, and sugar. In some cases 
3 



34 THE NOSE AND ACCESSORY SINUSES 

albumin will not be found at first, but after a few years its presence may 
be detected. In other words, the dryness of the pharynx is by some 
regarded as one of the earliest symptoms of this disease. 

Edema of the glottis, causing laryngeal stenosis, is often due to uremia 
developing as a result of Bright's disease. In the milder forms of uremia, 
bronchial asthma and hemorrhage of the upper air passages are some- 
times found to be the chief expressions of the disease. In the more 
pronounced uremic conditions there may be aphasia from edema of 
the brain. 

(e) Proximity of Organs.— The close proximity of the organs of the 
head favors a correlated pathological activity. The eye is near the 
nose and has immediate communication with it through the tear duct, 
as well as through the lymphatics, the bloodvessels, and the nervous 
system; hence, disease in one often gives rise to certain symptoms in the 
other. Experiments with certain colored solutions dropped into the eye 
have sho\Aai the coloring matter within a very short time in the nasal 
mucous membrane. The instillation of bacteria yields the same results. 
Clinically it is not uncommon to observe an inflammatory condition in 
the eye simultaneously with or following a similar process in the nose. 
I have often had cases referred to me by ophthalmologists wdio w^ere 
unable to prescribe satisfactory glasses until after I had corrected the 
nasal condition, usually involving the middle turbinated body or the 
ethmoid cells. The proximity of the nose to the ear, as well as the 
physiological communication between them via the Eustachian tube, 
gives rise to a very intimate relation between these organs. 

It is well known that inflammation of the epiphar\Tix sometimes extends 
through the Eustachian tube, by continuity of tissue, to the middle ear. 
This condition may develop until there is suppurative otitis media, 
mastoiditis, and even intracranial complications. Adenoids are also 
a fruitful source of mischief to the ear and the mastoid process. They 
may mechanically obstruct the Eustachian tube, or the epipharyngitis 
which almost invariably accompanies them may cause the ear disease. 
The removal of adenoids in children is often followed by immediate 
I'elief of deafness or even of suppurative inflammation of the middle ear. 

While the stomach is not so closely related to the ear as the epipharynx, 
nevertheless it has a close pathological and anatomical connection 
through the esophagus. In vomiting, foreign matter may be forced into 
the Eustachian tube and the middle ear, and may cause otitis media, 
with all its attending complications. From this same organ eructations 
of gas may also cause irritation in the epipharynx and the Eustachian 
tube. 

The nasal discharges, especially when there is empyema of the acces- 
sory sinuses of the nose, usually pass backward into the epipharynx 
and cause irritation and inflammation in this region. They also pass 
to the larynx and cause more or less trouble there. Stenosis of the nose 
interferes with the functions of that organ, and thus allows the air to 
pass into the epijiharvnx, the larynx, and the bronchial tubes insufficiently 
warmed, insufficiently moistened, and imperfectly filtered. Irritation 



ELEMENTARY FACTS 35 

of the mucosa of the respiratory tract below it is thus caused and gives 
rise to catarrhal inflammation. 

The ear is separated from the cranial cavity by a partition of bone 
which in places is not more than one-sixteenth to one-eighth of an inch 
in thickness. Chronic suppuration within the middle ear and the 
mastoid cavity often results in necrosis of this thin plate of bone, thus 
opening a channel of communication between the middle ear and the 
cranial cavity. The sequels or complications of mastoiditis, such as 
meningitis, brain abscess, septic thrombophlebitis, etc., may thus result 
from ear disease. 

The nose is but slightly separated from the cranial cavity, and through 
the ophthalmic veins may cause thrombophlebitis of the cavernous 
sinuses, which is attended by such fatal consequences. 

(/) Infections. — Systemic infections from the upper respiratory 
tract have already been more or less considered in this chapter as well 
as in the one on the Tonsils as Portals of Infection; hence, the subject 
will not be elaborated here. 

(g) The Central Nervous System. — It is obvious, inasmuch as the 
central nervous system supplies the innervation of the nose, throat, and 
ear, that in disease of the central nervous system the parts which it 
supplies with innervation must be affected. In other words, in certain 
diseases of the central nervous system some of its characteristic symp- 
toms may be found in the upper respiratory tract. 

In tabes dorsalis there may be certain motor laryngeal disturbances, 
which may be either bilateral or unilateral. There may be ataxic 
movements of the vocal cords. Laryngeal crises, as spasmodic cough, 
may be present. 

Ear symptoms in tabes are rare. The cochlear and vestibular nerve 
endings may, however, be congested. In this event there will be 
diminished or entire absence of bone conduction and hearing for the 
higher tones. Meniere's symptom-complex may also be present in excep- 
tional cases. 

In multiple sclerosis the laryngeal symptoms are a tremulous voice, 
which is easily fatigued, and is deep and hoarse in character. Muscular 
palsy of the laryngeal muscles is rare. The ear symptoms in this 
disease are tinnitus, and loss of hearing by bone conduction through 
the sclerotic degeneration of the nuclei. 

The symptoms found in paralysis agitans are about the same as those 
found in multiple sclerosis. 

(h) The Lymphatic System. — There are certain constitutional symp- 
toms due to infections tlirougli the lymphatic system which should be 
especially singled out, although they have already been referred to in 
Section (a) of this chapter. 

We now recognize that a fever, characteristic of childhood, which has 
heretofore been regarded as one of the ill-defined malarial infections, 
is due to an infection through the adenoid growths in the nasopharynx. 
The fever usually runs an irregular course of aliout ten days, and is 
characterized by an afternoon temperature of 100° to 104° with rest- 



36 THE NOSE AND ACCESSORY SINUSES 

lessness, peevishness, sharp pains through the ears at night, anemia, 
general debiHty, loss of appetite, coated tongue with indentations from 
the teeth, constipation, and cervical adenitis. jNIouth breathing is 
not essential as a factor in causing the infection. A small amount of 
lym])hatic tissue in the epipharynx is a sufficient portal for the entrance 
of the bacteria. The presence of this type of fever is almost always 
an indication for the removal of the adenoids. If the child is known to 
be tuberculous, some consideration may be given to the matter before 
removing them, for, if the removal is imperfectly done, it may give rise to 
a recrudescence of the tuberculous infection, which may extend to the 
lungs and lead to a fatal issue. 

Another ])lood disease which may express itself through certain patho- 
logical changes in the ear, nose, and throat is syphilis. The nose may 
be the primary seat of the lesion, the infection taking place in the removal 
of crusts from the septum with the finger. The tonsils are occasionally 
the seat of the primary lesion or chancre through the use of infected 
instruments in the throat. The author has seen cases in which both 
tonsils were the seat of chancre as a result of the instruments used in 
lancing the tonsils during an attack of peritonsillar abscess. 

In one case there was the characteristic initial lesion in the left tonsil, 
with the cervical bubo on the same side, which was followed a few 
days later by the characteristic skin eruption. The source of the infection 
in this case was the dirty instruments used in lancing a peritonsillar 
abscess. I first saw the case six weeks after the tonsils were lanced. 
The patient had been complaining of sore throat for two or three weeks. 
The tonsils and the bubo were still very much in evidence and the 
eruption on the skin had just begun to show. In the course of another 
week the corona veneris developed. The copper-colored eruption on the 
face showed much plainer at a distance of twelve or fifteen feet than it 
did when viewed near by. 

Secondary syphilis may manifest itself by mucous patches in the 
buccal cavity, by hyperemia of the larynx, hoarseness, and syphilitic 
coryza with scanty, thick secretion from the nose. Syphilitic coryza 
is not always recognized by the family physician, being regarded as a 
simple ol)stinate cold in the head. The scanty, thick discharge, with 
stenosis of the nose, should, however, excite suspicion of the true nature 
of the disease. 

I once saw a case in which there was a marked arrest of development 
of the bones of the face because, when in childhood the syphilitic coryza 
developed, the family ])hysician regarded it as an ordinary cold. He 
treated him for the same without success, and was finally surprised to 
find the nasal bones and the septum giving way. The soft palate and 
the ])harynx later became involved and rapidly melted away under the 
blighting influence of the sy])hintic poison. The patient is now thirty- 
four years old, and has the most pronounced "frog" face I ever have 
seen. Adhesive bands ])ind the soft palate to the pharvngeal wall, 
making it difficult for him to s{)eak distinctly, though he is now 
successfully engaged in business. 



ELEMENTARY FACTS 37 

The tertiary manifestations of syphilis are syphihtic pharyngitis 
and laryngitis, with a raucous voice. Syphilitic lesions of the tonsils, 
presenting a dirty grayish necrotic surface resembling diphtheria, are 
occasionally observed. Syphilitic gummata are not excessively destruc- 
tive in character. Syphilitic papillomata of the tonsils and the soft 
palate are elsewhere described. 

Recent investigations have discredited the oft -repeated statement that 
the skin and the mucous membranes of the animal organism are insur- 
mountable barriers to microorganisms so long as the epithelial coat is 
intact. Bono and Frisco report that the researches undertaken at the 
Institute of Hygiene at Palermo have established the fact that "germs 
deposited on the intact skin or mucosa are found soon afterward in the 
lymphatic ganglia of the respective regions. If the germs are so numerous 
or so virulent as to overcome the resistance offered by the lymphatic 
ganglia, general infection may result. If not, there is merely a local 
reaction on the part of the ganglia, which become tumefied and undergo 
various modifications in their structure proportional to the number of 
germs which reach them." 

To establish the relationship between the nasal mucous membrane 
and the eye, microorganisms were placed on the nasal mucous mem- 
brane, both with and without obliteration of the nasolacrymal canal. 
The result of the experiments showed the penetration of the germs into 
the vitreous and the aqueous humors of the eye on the same side. 

"None of the animals exhibited any signs of general infection. One 
or two colonies, at most, could be derived from the blood in the heart, 
the liver, the spleen, and the lymphatic ganglia of the neck, and occasion- 
ally from the anterior auricular, the submaxillary, the deep jugular, 
and the carotid lymphatic ganglia. This fact, considered in connection 
with the presence of large numbers of germs in the aqueous and the 
vitreous humor, and the absence of general infection, warrants the con- 
clusion that the bacteria penetrated directly into the eye from the nasal 
and the conjunctival mucous membrane, and that they also arrived 
secondarily in the eye through the blood, but reduced in numbers and 
virulence. Part of the germs were retained by the ganglia connected 
with the anterior lymphatic vessels of the eyeball and its appendages. 
In further experiments with instillations of India ink it was possible to 
trace the exact route followed by the particles from the conjunctival 
lymphatics along Schlemm's canal into the anterior chamber and thence 
into the vitreous. From the lymphatics of the nasal mucosa the particles 
passed into the ethmoid cells and the lamina papyracea, thence into 
Tenon's capsule, and on into the eyeball. The practical results of these 
researches are particularly important in the pathology of the eye." 

Eye Diseases Due to Nasal Lesions (especially Optic Nerve Lesions). 
— F. Mendel, after observing many cases, comes to tlic conclusion that 
the nasal infection and inflannnation is transferred to the eye by the direct 
connection or continuance of the epithelium of the nasal mucous mem- 
brane to the conjunctiva, as well as by the intimate vascular association. 

The ophthalmic artery gives off the anterior ethmoidal, which supplies 



38 THE NOSE AND ACCESSORY SINUSES 

the nose and the lacrymal canal. The venous supply of the nasal 
mucous membrane, by means of the lacrymal plexus, is in direct com- 
munication with the ophthalmic vein. 

Heber Nelson Hoople, in a paper read before the American Laryn- 
gological, Rhinological, and Otological Association, 1901, advances the 
theory that faulty pressure within the nose can cause asthenopia of 
both the ciliary and external ocular muscles. That is, mechanical 
pressure in a limited area of the nose, called by Mackenzie the reflex 
area, can cause muscular asthenopia. By muscular asthenopia he 
means the impairment of the efiiciency of the ocular muscles in the 
performance of their ordinary functions. 

The pressure to which Hoople refers is confined chiefly to the middle 
turbinal, especially to great enlargement of the middle turbinated body, 

A concomitant symptom usually occurring in conjunction with the 
asthenopia is a browache or headache referred to the frontal region or 
to the occiput in rarer instances. 

He cites a number of cases in his own practice and in that of others 
in which the asthenopia disappeared as soon as the nasal trouble was 
cured. The asthenopic cases referred to belong to the so-called normal 
type rather than to the excessive type. 

He concludes that a moderate amount of pressure or mechanical irri- 
tation of the middle turbinated body against the adjacent septum will 
temporarily impair the function of the ciliary muscle; to a lesser or more 
variable degree, it will also impair that of the external ocular muscles. 
If mechanical irritation (from congestion or swelling of the soft tissues) 
can impair the function of these muscles, how much more would a con- 
tinuous pressure from a septal spur or other deviation of the septum 
digging into the middle turbinal keep up this impairment ? 

The reason for the association of headache with asthenopia is that they 
have a common cause — pressure upon the sensori-motor branches of the 
trigeminus. So far as the sensory part is affected, a radiated or a reflex 
headache is produced; so far as the sympathetic fibers are affected a 
vasomotor reflex is produced. This is equally true where there are 
inflammatory conditions, as ethmoiditis. It matters little whether 
the pressure is from within the ethmoid cells and turbinal or from with- 
out these structures. The important point is that the same branches 
of these nerves are pressed upon, and, therefore, the same kind of dis- 
turbances should be expected to follow. 

The asthenopic disturbance is probably due to irritation of the sym- 
pathetic fibers in this particular class of cases. That it is such in all 
cases is also probable. It could be inferred from other facts, e. g., when 
treatment addressed to the uterus, the bladder, or the stomach has given 
relief of the asthenopic symptoms. 

In the light of the foregoing views expressed by Hoople, asthenopia or 
disturbed function of the ciliary and external ocular muscles is usually 
due to intranasal pressure and irritation in the middle turbinal and 
ethmoidal regions, rather than to toxemia from infection of the sinuses. 
The speedy relief of the asthenopia following the divulsion or the removal 



ELEMENTARY FACTS 39 

of the offending middle turbinal seems to prove this view rather than the 
view referring the disturbance to toxemia. 

In the cases referred to by Hoople the headaches were of the ocular 
rather than the sinus type, as they were induced, or aggravated, by the 
use of the eyes, and were relieved upon retiring for the night. Sinus 
headache is not always aggravated by using the eyes, and is often most 
pronounced upon awakening in the morning or in the night. 



CHAPTER III. 

THE OFFICE EQUIPMENT. 

The chief thought in the equipment of an office should have reference 
to facihty in handhng and treating patients. The treatment and consul- 
tation rooms should be equipped for work rather than for entertainment. 
Ever}^hing for facility and thoroughness; nothing for show. "Bluff" 
is a confession of unfitness. Thorough knowledge and frankness of 
statement will inspire confidence and give an impression of mastery as 
no amount of bluffing will do. 

The essential furnishings of the consultation-room and treatment- 
room should consist of the following outfit : 

(a) Treatment and operating chair. (6) A revolving stool for the 
surgeon, (c) A treatment table or cabinet, {d) A fountain cuspidor, (e) 
A linen cupboard. (/) A writing desk, {g) A sterilizer, {h) A revolving 
desk chair, {i) Tw^o small chairs, {j) An adjustable bracket for the 
examination lamp, {k) A selection of instruments and apparatus for 
examinations, treatments, and operations. 

The Treatment and Operating Chair.— The treatment and operating 
chair should have a revolving bottom, as suggested by Dr. Robert Levy, 
as it is desirable to turn the patient from side to side in treating his ears, 
and for other reasons as well. The bottom should be on a central screw 
pin, so that it can be adjusted to different heights for children and adults. 
The back should be so constructed that it can be lowered on a level with 
the bottom in case of faintness and in case it is desirable to operate in a 
prone position. An adjustable head-rest should be attached to the back 
of the chair. Chairs responding to the foregoing requirement are 
shown in Figs. 6 and 7. An ordinary chair may, of course be used, but, in 
the case of faintness, etc., the work is greatly facilitated and the comfort 
of the patient assured if the chair is of the adjustable type described. 

The Treatment Table or Cabinet. — If an assistant is employed it is 
preferable to have the instruments in a separate cabinet adjoining the 
sterilizing room or corner. The treatment cabinet may then consist of 
a metal enamelled frame with a plate-glass top, or it may be a double- 
decked table, with top and shelves about one foot apart. These tops 
afford ample room for the distribution of bottles containing remedies 
for topical applications and for the instruments of examination and 
operation. 

The treatment table or cabinet (Fig. 8) is an important item of furniture. 
Its selection should depend largely upon whether the surgeon has an 
assistant or nurse to wait upon him. If he has such an assistant the 
cabinet need not be constructed to contain all his instruments, as the 



THE OFFICE EQUIPMENT 



41 



assistant will bring the necessary instruments for each case. If he does 
not have an assistant, it is convenient to have the instruments in the 
cabinet within his reach. 

The Hot-water Basin. — A most excellent addition to the table is a 
basin set in the centre of the upper glass top, with running hot water for 
rinsing instruments during the course of treatments. If preferred, the 
hot- water basin may be attached to a special wall bracket (Fig. 9), 
as it is only intended to provide a convenient arrangement for rinsing 
instruments during treatments and operations. It is also convenient for 




c^*^ 




Operating chairs. 



cleansing and warming the laryngeal mirror during throat examinations. 
No matter how sterile the tongue depressor is when brought in, its 
introduction into the mouth the second or third time without cleansing 
is, to say the least, disgusting to the patient. 

A basin of running hot water is, therefore, an invaluable, and I might 
add an indispensable, adjunct to the office equipment. It is not indis- 
pensable in so far as the safety of the patient is concerned, as only his 
own secretions contaminate the instrument used. If the fundamental 
principles of common cleanliness are to be recognized it is a valuable 



42 



THE NOSE AXD ACCESSORY SINUSES 



and necessary office fixture. It is not a question of whetlier it pays, but 
rather one of common decency, and that always pays. 




Clark's hot-water basin. 



Clark's fountain cuspidor. 



A bowl of antiseptic solution is not a substitute for running hot water 
unless the bowl is refilled for each rinsing. The solution w^ould soon 
become thick with secretions and detritus, and the introduction of an 



THE OFFICE EQUIPMENT 



43 



Fig. 11 

„ 4s 



instrument into it for rinsing purposes would be even more digusting 
than no rinsing at all. 

The Examination Lamp. — ^The examination lamp may be a kerosene, 
gas, or an electric lamp, preferably the latter, as it gives off less heat and 
requires less attention. The lamp may or may not have a hood with a 
focusing lense, according to the preference of the surgeon. Personally, 
I prefer an electric lamp of 50 candle-power 
(Fig. 11), with a ground-glass surface except 
a circular area on one side, where the glass 
is clear. This affords plenty of illumination, 
is simple, throws out little heat, and is inex- 
pensive. / 

A wall bracket to support the lamp is an I 
important item, inasmuch as it is constantly I 
used, and should, therefore, be well constructed \ 
and accommodate itself to the varying con- 
ditions under which it is used. That is, it 
should be so constructed that the lamp can 
be raised and lowered and turned from side 
to side with the least trouble to the operator. 
It should be so well made that it will never get 
out of order, a state or condition into which 
many wall-lamp brackets are prone to lapse. 
That shown in Fig. 12 has proved quite satis- . ^^ ,, , , . 

o r 111 A 50 candle-power electric 

factory m nearly every respect, though the lamp. 





t'all-lamp bracket. 



electric bulb attached should be turned upward. A Kierstein head 
lamp (Fig. 13) is preferred l)y some operators. 

Compressed-air Apparatus. — The compressed-air apparatus may 
be one of three types: (a) A hand bulb; (6) a tank pumped by hand or 
some automatic device, as a water pump; or (c) a system of com- 
pressed air supplied throughout the building by means of pipes from 
a central compressed-air tank. The latter is preferable when it can 



44 THE NOSE AXD ACCESSORY SINUSES 

he obtained, as it requires no attention whatever. A compressed-air 
tank in the office automatically supplied by means of an hydraulic 
pump is the next most preferable arrangement. A hand pump is incon- 
venient and entails considerable labor. The hand bulb is suitable when 
eight pounds or less of pressure is required. 

An Accessory Regulating Air Tank. — An accessory regulating air 
tank is a very convenient and valuable addition to the compressed-air 
system, as it enables the surgeon to use the amount of pressure required 
for various purposes. The nasal mucous membrane, for example, will 
not tolerate a higher pressure than ten pounds with the De Vilbiss spray 
tube, whereas the pharynx will tolerate from twenty to forty pounds' 
pressure. A nebulizer requires a higher pressure than the spray tube, 
and in inflation of the Eustachian tube and middle ear the pressure 
required varies from eight to twenty pounds, according to the degree 
of obstruction present. Hence a regulating air tank is a convenient 




Kierstein lamp and head bracket . 

if not a necessary apparatus. The tank should be connected with 
the main reservoir and the compressed air turned on until the gauge 
indicates the required pressure, say twenty pounds. If at another 
time in the treatment but ten pounds' pressure is needed the escape valve 
may be opened until the gauge indicates ten pounds. There are many 
other ways in which such a regulating air tank may be used to advantage. 
The gauge regulators on the market are not nearly so satisfactory as the 
regulating tank, and are not recommended. 

Massage Apparatus. — Ear Drum. — Pneumomassage or the massage 
of the ear (liuiii by the alternate rarefaction and condensation of the air 
in the external auditory meatus is accomplished by means of a hand 
pump, as first devised by Delstanche, of Brussels (Fig. 14), or it may be 
operated by an electric motor, as first devised by Chevalier Jackson, of 
Pittsburg, and later, in 1893, improved by Pynchon (Fig. 15). The 
pneumomassage of the ear drum is recommended in deafness and ear 



THE OFFICE EQUIPMENT 



45 



noises of catarrhal origin, though its vahie has been greatly exaggerated. 
Delstanche was of such high repute, that he was awarded the Lavele prize 




Delstanche's rarefactor and artificial leech. 
Fig. 15 




The Victor electrocautery and 



for having designed the best instrument for relief of deafness, hence 
the procedure was adopted by aurists all over the world. Subsequent 



40 THE NOSE AND ACCESSORY SINUSES 

experience with it and its modifications has not met the high expectations 
with which it was received. Pneumomassage has a place in aural 
practice, however, as by it the mucous membrane is brought into a 
more active and resistant state, and the labyrinth is also stimulated to 
greater functional activity by it. The ossicles of the ear are rendered 
more mobile and transmit sound better after its application in a limited 
number of cases. Tinnitus is also occasionally improved by it. Such 
cases require rare skill and knowledge to determine what is best to do 
for them. Routine of inflation and of pneumomassage lead to bitter 
disappointment except in a few cases. Accurate diagnosis is of first 
importance; then the treatment should be very carefully and intelligently 
prescribed. Not every case of deafness and tinnitus is improved by 
pneumomassage or any other method of treatment. 

Then, too, the massage apparatus, hand or mechanically driven device, 
should be regulated to suit each case. The length of the piston stroke, 
the frequency of the vibrations, and the length of time the massage 
should be used are questions to be settled according to the peculiarities 
of each case and the experience and judgment of the surgeon. Massage 
per se is of no value as a therapeutic agent. It is only when it is mixed 
with "brains" that it becomes of value. Surgeons who are uninformed 
and inexperienced are often tempted to furnish their offices with formid- 
able looking mechanical devices, with the belief that they are thus pre- 
paring themselves to adequately cope with disease. If they are intelli- 
gent observers, they soon learn that the "man behind the gun" is the first 
requisite for the attainment of success. I must confess that I have 
rarely observed marked improvement in deafness and tinnitus that was 
clearly due to pneumomassage. 

I have, however, found the hand apparatus of Delstanche of the great- 
est value as a diagnostic agent. With it the ear drum may be observed 
under compression and rarefaction, points of adhesions and of atrophy 
being clearly demonstrated. When the air is rarefied in the meatus the 
ear drum is pulled outward, the points of adhesion being fixed while the 
balance of the membrane bulges outward, leaving no room for doubt as to 
the condition of the middle ear. If there is an atrophic area in the ear 
drum it bulges like a blister beyond the balance of the membrane. If 
the otoscopic portion of the apparatus is provided with a magnifying 
lens the texture of the ear drum is clearly demonstrated. 

Aside from the diagnostic value of the Delstanche apparatus its greatest 
usefulness is in the treatment of the exudative forms of middle-ear 
catarrh. It is in the protracted course of these cases that the adhesive 
processes form. The viscid exudate agglutinates the ear drum to the inner 
tympanic wall, becomes organized, and thus permanently fixes it to the 
inner wall of the middle-ear cavity. The timely and intelligent use of 
the Delstanche rarefactor, or other pneumomassage apparatus, may 
prevent ])ermanent adhesions. The apparatus should in the beginning 
be used daily with a slow, long stroke of the piston. After the inflam- 
matory })rocess has abated and the exudate is less viscid antl less profuse 
the treatment may be gradually reduced in frequency and finally aban- 



THE OFFICE EQUIPMENT 47 

doned. The length of the stroke (force of the suction) should be grad- 
ually diminished, as a too long-continued stretching of the membrana 
tympani will render it abnormally lax from pressure (suction) atrophy. 

Aiiother device for the massage of the ear drum consists of a glass 
tube partially filled with metallic mercury (Fig. 16). The open end of 
the tube is shaped to fit the external meatus, and when not in use is 
closed with a rubber cork. Its application is simple, the uncorked end 
being placed firmly in the external meatus, and the patient instructed to 
move the head from side to side, allowing the mercury to drop against the 
ear drum. This procedure is repeated several times at each daily seance. 
According to Dr. Joseph C. Beck-, its originator, the rationale of its use 
consists in the impact of the mercury against the malleus and ear drum, 
the force being transmitted to the entire ossicular chain and to the 
labyrinth. This stimulates the functional activity of these structures 
and improves the condition present. Dr. Beck has found its chief useful- 
ness in the relief of the tinnitus rather than the deafness, a fact which 
to my mind is significant. That is, the mechanical shocks thus applied 
to the membrana tympani and transmitted to the labyrinth affect the 
circulation of the labyrinth, improve the nutrition and increase the local 
leukocytosis. These changes affect the labyrinth in such a way as to 
relieve the tinnitus. 




Beck's mercury massage. 

Dr. Beck has also noted that the improvement was usually transient, 
lasting only a few days or weeks after discontinuing the treatment. 

The Electrocautery. — So much has been said within the past six 
years about the use, or rather the uselessness, of the electrocautery 
(Fig. 15) that I feel impelled to rise in its defence. It is still a very use- 
ful apparatus, and an office is incomplete without it. It is true that it 
has been too frequently, indiscriminately, and unintelligently used, but it 
still fills a place of great usefulness in the armamentarium of the specialist. 
Its usefulness in turgescent rhinitis has been greatly abridged by the 
improved methods of operating upon the nasal septum (notably the sub- 
mucous resection), but even in this condition it still aft'ords a means of 
temporarily overcoming the excessive swelling of the inferior turbinated 
bodies. It also affords a valuable means of treating chronic granular 
pharyngitis witli lymphoid enlargements along the lateral and posterior 
walls of the pharynx. Still other uses could be described, but as they 
are mentioned in connection with the respective diseases, the two 
citations are sufficient to show that the electrocautery apparatus is not 
an obsolete instrument. 

Spray Tubes. — Tlie spray tubes and the medicated fluids used in 
them have also come under tlie ban as therapeutic agents. There was 
a time when the rhinologist and laryngologist was called the "spray 



48 



THE NOSE AXD ACCESSORY SIXUSES 



specialist," more derisively the "squirt-gun doctor." Whatever grounds 
there may have been for these charactei-izations it is certain that they do 
not apply to the specialist of the present time. Nearly all special sur- 
geons now recognize the futility of attempting to cure diseases of the 
nose and throat by means of medicated water and oil. The etiology 
of the catarrhal and suppurative inflammations of the nose and throat is 
better understood, and the ideas concerning their treatment have under- 
gone corresponding changes. It is being more and more recognized that 
mucous-lined cavities are subject to catarrhal and infective inflammation 
somewhat in proportion to the degree of obstruction to their drainage 
and ventilation. This one factor is probably the most significant etiolog- 
ical factor emphasized in recent years. Goodale and Jonathan Wright 
emphasize it in reference to the crypts of the tonsil. Heath has recently 
emphasized the same truth in reference to the mastoid antrum and the 




De \'ilbiss' atomizer and nebulizer. 



middle ear. (See Heath's Masinid Operation; also the Clinical Anatomy 
of the Nose, and the Inflammatory Diseases of the Nose and Accessory 
Sinuses.) 

In view of this more modern conception of the etiology of the inflam- 
matory diseases of the ear, nose, and throat, surgical procedures have 
largely replaced the topical, medical, and caustic applications once in 
popular favor. The spray tube or atomizer occupies a less conspicuous 
place than it did a few years ago (Fig. 17). An array of fifty or a 
hundred spray bottles, each with a different medicated or perfumed 
solution, is no longer a necessary part of an office outfit; indeed, such an 
array of spray formula is in some ways a confession of an antique, if 
not altogether obsolete, conception of medical practice. Spray tubes 
are, nevertheless, necessary adjuncts to the office outfit, as they should 
be used to cleanse the nasal and throat cavities before operating and to 
treat acute and chronic inflammations. 



THE OFFICE EQUIPMENT 



49 



The Mechanical Vibrator. — Some years ago the mechanical vibrator 
was mentioned as acting favorably upon tinnitis and deafness, but its 
more general use by English and American otologists has demon- 
strated its comparative uselessness for these purposes. At that time 
it was stated that when applied over the spinal column it seemed to act 
favorably upon the ear. I have tried it faithfully for this purpose, with 
no appreciable effect. Its chief field of usefulness is in reducing the 
swelling and sensitiveness of the glands of the neck and the headache 
accompanying the various sinus affections. But even these conditions 
are better and more pleasantly ameliorated by the leukodescent lamp. 
The vibratory or mechanical massage increases the lymphatic flow, 
improves the nutrition, and increases local leukocytosis. Hence, it 




Pynchon's modification of Dabney's vacuum aspirator 



leukodescent therapeutic lamj). 



relieves pain and tenderness, and reduces the activity of an inflammatory 
process, provided it can be applied to the parts. In this respect it acts 
upon the principle of Bier's constriction and negative pressure treatment, 
and the leukodescent-light treatment; that is, they each increase the local 
leukocytosis, improve the local nutrition, and thus diminish the inflam- 
matory y)rocess. 

Negative Pressure Apparatus.— This apparatus consists of a device 
whereby the air pressure is reduced in the upper air passages, notably 
the nose and accessory sinuses (Fig. 18). The negative air pressure 
within the nose and accessory sinuses facilitates the* discharge of the 
secretions and purulent accumulations, increases the local nutrition and 
leukocytosis, and acts favorably upon the inflammatory process. Its chief 
4 



50 THE NOSE AND ACCESSORY SINUSES 

field of usefulness seems to be in the treatment of the subacute inflamma- 
tions of the sinuses, though it exerts a favorable influence upon chronic 
sinuitis. 

The Leukodescent Lamp. — The leukodescent lamp is a single incan- 
descent globe of 500 candle-power (Fig. 19), around which is placed a 
reflector eighteen inches in diameter. The reflector focuses the rays of 
light, thus increasing their penetrating power. The therapeutic properties 
of the leukodescent light is in the heat and chemical rays. The leuko- 
descent light is rich in blue-violet rays, in addition to the light and heat 
rays. The blue-violet are very active chemical rays and increase the 
tissue metabolism and the leukoc^-tosis, thus providing for the destruction 
of the pathogenic bacteria. 

Clinically, I have found the leukodescent light of value in inflammatory 
and infectious processes. For instance, I have seen cases of chronic 
maxillary empyema with granulations cease discharging under its 
influence. The pain, tenderness, and swelling likewise disappeared. 
In no case, however, have I seen a cure by this mode of treatment. In 
acute sinuitis I have seen marked and rapid improvement follow its 
use. Infective inflammation of the mastoid W'Ound rapidly improves 
under its use three times daily. Cervical adenitis usually responds 
readily to the rays. Pain of almost any origin is relieved and in many 
cases stopped by it. The pain of sarcoma is almost invariably checked. 
It seems to exert a slight control over an oozing postoperative hemorrhage. 
Its power to increase tissue metabolism and local leukocytosis reduces 
the bacterial activity. The latter is probably due more to the increased 
leukocytosis than to the bactericidal property of the rays. While they are 
bactericidal when applied continuously for ten minutes at a distance 
of thirteen inches in the laboratory, they are probably not batericidal 
at eighteen inches for a few moments at short intervals in their clinical 
application. The rays are too hot to be tolerated constantly at close 
range, hence the effects produced in laboratory experiments cannot be 
duplicated in actual practice. 

Lamps of less candle power are correspondingly poor in the blue- 
violet rays, the 50 candle-pow^er lamp having scarcely a trace of them. 
It has also been shown that ten 50 candle-power lamps in group have 
indentically the same quality of rays as a single 50 candle-power lamp, 
and that the rays are in no way similar to those given off by a 500 candle- 
power lamp. I therefore recommend that a single 500 candle-power 
lamp be chosen, as a lamp of less capacity is not sufficiently rich in 
chemical rays to ])roduco the best results. 

A Sterilizer for Instruments and Gauze.— An office outfit is not 
complete without a sterilizer of some kind. All instruments should be 
boiled for at least twenty minutes before they are used, for either examina- 
tions, treatments, or surgical operations. The instruments may be boiled 
in a porcelain-lined bucket or pan, or in a specially designed sterilizer, 
as shown in Fig. 20. The apparatus shown in the illustration is 
provided with a drying chamber in addition to the boiling tray, and is 
recommended on this account. Instruments are often damaged or 



THE OFFICE EQUIPMENT 



51 



altogether ruined because they are not dried after being steriHzed. 
With this sterihzer they may be boiled and dried after an operation. 

Topical Applications. — ^Topical remedies which should be upon 
the treatment table are numerous, though individual preference may 
greatly modify their number and character. I shall only refer to those 
which have proved satisfactory in my practice. 

Nitrate of Silver. — ^The following solutions of nitrate of silver should 
be kept on the treatment table in blue-glass bottles, or in a cabinet within 
convenient reach of the surgeon or his personal assistant. 



'Bj,. — Argenti nitratis 
Aquae des. 



Sf^M. 

This is approximately a 2 per cent, solution of the silver salt, and is 
useful where a mild but positive astringent action is required, as in 
simple subacute catarrhal inflammations of the upper respiratory tract. 
It may be applied with a spray tube, the essential parts of which are made 
of hard rubber and aluminum, or of glass. Other metals are acted 




Pynchon's sterilizer and instrument dryer. 

upon by the silver salt, and are not suitable for the silver solutions on 
this account. The silver solution may also be applied with a cotton- 
wound applicator. A camel's-hair brush is not recommended, on ac- 
count of the difficulty of keeping it sterile. 

I^. — Argenti nitratis gr. xx 

Aquae des 5J — M. 

This solution is approximately 4 per cent, in strength, and may be 
used as No. 1 when a more positive astringent and antiseptic action is 
required. 

I^. — Argenti nitratis gr. xl 

Aquae des 5J — M. 

This solution is approximately 8 per cent, in strength, and is useful 
in the more chronic catarrhal inflammations of the upper respiratory 
tract. Solutions of greater strengtli than this are rarely indicated in 
chronic inflammations of the mucous membrane except when a caustic 
action is required. Higher strengths are apt to cause irritation and an 
aggravation of the local chronic inflammation. 



Oj 



THE NOSE AXD ACCESSORY SIXUSES 



In the very acute inflammations a much higher percentage of silver 
may be used. 

I^. — Argenti nitratis oss 

Aquse des q. s. ad 5J — ^^^ 

This is a 12?, per cent, solution and is a valuable local remedy in acute 
lacunar inflammation of the tonsils. The more acute the attack and 
the more edematous the tissue the stronger the silv-er solution should be. 

I^. — Argenti nitratis oij 

Aquae des q. s. ad 5J — ^I- 

This is a M) per cent, solution and is useful as a local application in acute 
infectious inflammations of the fauces and the nasopharynx. It is 
especially useful in acute lacunar tonsillitis, one application in the 
primary stage often being sufficient to abort the inflammatory process. 

I^. — Argenti nitratis gr. ccccxxxij 

Aquae des q. s. ad 5J 

This is a 90 per cent, solution and is useful in acute lacunar tonsillitis 
in the most \'irulent and acute stage. It should only be applied when 
the inflammation is very recent and aggravated in type. The tissues 
should be succulent and highly inflamed. In such a case of acute 
lacimar tonsillitis it is a specific remedy. I have never seen a case 
corresponding to the above description in which a second application 
of the remedy was necessary. Its use in this strength is not painful, but, 
on the contrary, relief immediately follows its use. 

If this strength of solution were applied to a subacute inflammation 
the chemical trauma would probably aggravate the existing inflammatory 
process rather than relieve it. Solutions of silver salt in the higher 
strengths coagulate the mucous secretions and blanch the surface of 
the inflamed mucous membrane. It is also a powerful germicide. 
The inflammatory infiltration of the tissue is checked and the vitality 
of the infective bacteria is lowered or destroyed. 

A caution as to the use of silver nitrate. The silver salt in any strength 
has a marked irritating effect on the intrinsic muscles of the larN-nx. 
To avoid this accident the cotton-wound applicator shoukl be freed of 
the excess of the solution by squeezing it with a liberal wad of cotton. 
When this is done the inflamed area should be lightly brushed with it. 

Silver Maxims. — (a) The milder the inflammation the milder the 
solution, (h) The more intense the inflammation the stronger the solu- 
tion. 

Guaiacol Solutions. — Solutions of guaiacol in olive oil are useful 
local remedies in acute inflanmiation of the fauces and the pharynx. 

The strengths recommended are 10, 25, and 50 per cent, of guaiacol 
in ])ure olive oil. The more severe the inflammation the stronger the 
solution required. 

While guaiacol is not as efficient a remedy in acute tonsillitis as the 
stronger solutions of silver, it is nevertheless very positive in its action, 
many cases recjuiring but a few applications to check the inflammatory 



THE OFFICE EQUIPMENT 53 

process. It produces a pungent, hot sensation which lasts for about 
thirty seconds. 

Compound Tincture of Benzoin. — The compound tincture of benzoin 
is a valuable local remedy in the throat where a mild but positive astrin- 
gent and antiseptic remedy is indicated. It may be used in chronic 
granular pharyngitis during the mild exacerbations of the disease with 
good effect. 

Its chief value is as an adjunct in dressing the nasal accessory cavities. 
The gauze should be moistened in the solution, the excess removed by 
squeezing, and packed in the nasal cavity. It prevents decomposition 
and stimulates healthy granulations. A plain gauze dressing in the 
nasal chambers, if allowed to remain more than twenty-four hours, 
often takes on a very offensive odor. If the gauze is moistened with 
the compound tincture of benzoin, it may remain in the nose seventy- 
two hours without acquiring an offensive odor. 

A foul-smelling chronic otorrhea may be rendered sweet by mopping 
the cavity dry and applying a dressing of gauze moistened with the 
compound tincture of benzoin. 




SECTIDN SHDWING POWDER SCOOP 

Powder insufflator. 



Sub nitrate of Bismuth Powder. — This powder may be used with 
gauze dressings as a substitute for the compound tincture of benzoin. 
It also prevents decomposition, though not over so extended a period. 

It may also be insufflated (Fig. 21) into the nose after an intranasal 
operation, where it forms a coating which acts as a mechanical and a 
chemical protection to the underlying tissue. 

Ichthyol Solutions. — Ichthyol in aqueous and glycerin solutions may 
be used as a topical application in the nasal chambers where there is 
a foul or ozenic secretion. The nose should be packed with cotton or 
gauze saturated with the solution. Personally I prefer to use a cork- 
screw applicator wound with cotton and dipped in the ichthyol solution. 
This is then introduced into the nasal cavity and the applicator removed 
with a reverse screw motion, leaving the ichthyol pad in the nose. This 
should be left in place for from ten to thirty minutes, according to the 
degree of infection and tumefaction of the tissue. If the secretions are 
profuse and dried in the nasal cavities, the aqueous solution should be 
used; if there is a state of sepsis and local tumefaction of the tissues, the 
glycerin sohitioii should be used on account of its hygroscopic action. 

Iodine Solutions. — Iodine in a glycerin menstruum is a vahia])]e 
remedy in chronic granular phar>mgitis, and in tliosc cases of middle- 
ear catarrh associated with granular pharyngitis. 



54 THE NOSE AXD ACCESSORY SINUSES 

The following f orraul?e may be used in such cases : 

I^.— Tr. iodini Itlxlviij 

Glycerini q. s. ad 5J — M. 

I^. — lodoformi gr. j 

Potas. iodidi gr. x— xx 

Morphia sulphat is gr. j 

Glycerini 5j — M. 

I^. — Iodini gr. v-xx 

Potas. iodidi gr. x— xxx 

01. gaultheriae Ttlv 

Glycerini 5j — M. 

IJ.— Tr. iodidi, 
Tr. ferri chl., 
Glycerini . aa q. s. 5j — M. 

The fourth formula is very astringent and is used to promote even 
healing by granulation after tonsillectomy in adults. It is also of great 
value in the subacute type of granular pharyngitis. 

Carbolic Acid. — Carbolic acid may be used in any strength from 10 
to 93 per cent, aqueous or glycerin solution. 

IJ. — Carbolic acid gr. xx 

Glycerin 5j — M. 

This is approximately a 4 per cent, solution and may be used in sub- 
acute dry dermatitis of the external auditory meatus and in subacute 
otitis media. 

I^. — Carbolic acid 3 

Glycerin q. s. ad §j — M. 

This is a 12 per cent, solution and may be used in acute otitis media. 
It should be dropped into the meatus two or three times daily and a 
cotton plug introduced to prevent its escape. It is claimed that if 
dropped into the meatus in the initial stage of acvite suppurative otitis 
media it aborts the further progress of the inflammation in nearly every 
instance (A. H. Andrews). On the other hand it is claimed that its 
frequent use causes a fibrosis and thickening of the ear drum, and thus 
causes permanent diminution of hearing. It may be said, however, 
that its frequent use is not often required to abort an attack of acute 
otitis media. 

I^. — Carbolic acid gr. ccclvj 

Aquae des gr. xxiv — M. 

This is a 95 per cent, solution of carbolic acid and may be used when 
a superficial caustic effect is desired, as in infective granulomata of the 
middle ear and mastoid, either before or after operation. I have 
occasionally used it in old foul-smelling otorrheas to diminish the odor 
and to stimulate healthy granulation. 

It should be carefully dropped into the middle ear without allowing 
it to come in contact with the ineatal skin, and at the end of one minute 
alcohol should be instilled to check its action. 



THE OFFICE EQUIPMENT 55 

Alcohol. — Alcohol is also a valuable remedy for topical applications. 
I know of no better ingredient for a gargle than alcohol. It is astrin- 
gent and antiseptic, and, when properly diluted, is grateful to an inflamed 
surface. 

I^.— Alcohol, 

Cinnamon water aa Bij 

Formaldehyde tTlij 

Glycerin 3v 

Aquae des q. s. ad §viij — M. 

The above formula is a good gargle in acute tonsillar and pharyngeal 
inflammations and in the soreness following the removal of the tonsils. 

In very young children it may be used in a more diluted form. 

In chronic otorrhea alcohol may be used in the following dilutions 
and mixtures. 

I^. — Alcohol 1 part 

Aquae des. 2 parts — M. 

I^. — Alcohol 1 part 

Aquae des 1 part — M. 

I^. — Alcohol 2 parts 

Aquae des 1 part — M. 

I^. — Alcohol 3 parts 

Aquae des 1 part — M. 

IJi — ^Alcohol 95 per cent. 

The alcoholic dilutions given above are used principally in the treat- 
ment of chronic suppurative otitis media. 

They constitute the so-called "alcohol treatment" of this disease: 
The meatus is first filled with the weakest solution, then mopped out, 
and each solution applied in series until the patient tolerates the 95 per 
cent, solution. If the strongest solution is applied at once it causes 
considerable pain and irritation, whereas if the strength is gradually 
increased unpleasant results are avoided. 

Alcohol is a positive astringent and antiseptic remedy of considerable 
value. 

I^. — Alcohol (95 per cent.) 5j 

Boric acid gr. xx — M. 

I^. — Alcohol (95 per cent.) 5j 

Iodoform gr. v — M. 

The addition of boric acid and iodoform is supposed to give the local 
antiseptic effects of these drugs. If an excess of either drug is added, 
and the solution is agitated just before the instillation of the solution, 
a precipitate of the partially suspended drug is deposited on the diseased 
mucous membrane. 

These solutions should be used after having applied the weaker 
alcoholic solutions. 

Ointments. — Various drugs may be prepared with an oily menstruum, 
preferably lanolin, as it has greater aflfinity for the mucous membrane 



56 THE yOSE AXD ACCESSORY SIXUSES 

tlian vaseline. Pure olive oil may also be used as a menstruum. The 
following mixtures are recommended : 

I^. — Zinc oxide gr. xlviij 

Lanolin 5J — M. 

I^. — Zinc oxide gr. xlvij 

Morph. sulpli gr. g 

Atropine gr. yjij — M. 

The first formula is soothing to an inflamed surface, and may be 
applied in those cases in which there is an irritating mucous or sero- 
mucous discharge in catarrhal sinuitis. It is also of use in the massage 
of the nasal mucous membrane in rhinitis with collapse, and in turges- 
cence of the swell bodies. For this purpose a delicate silver applicator 
should be wound with a small wisp of cotton and dipped into the oint- 
ment. The nasal mucous membrane should then be gently massaged 
with the ointment, the probe being lightly held between the thumb and 
forefinger. The wrist movement, or the combined wrist and forefinger 
movement, should be used in performing the massage. The applicator 
should be held so lightly that if the cotton-wound applicator should 
strike a turbmated body or other obstruction the probe will slip through 
the fingers and do no damage. 

The sensitiveness of the mucous membrane may be quickly removed 
by the above procedure. 

The second mixture is of value when the nasal mucous membrane 
is sensitive and when there is an acute exacerbation of the inflammation. 
The morphine and atropine relieve the sensitiveness and reduce the con- 
gestion. 

I^. — Ichthyol gr. xlviii 

Lanolin §j — M. 

The ichthyol ointment may be used in those cases where the secretions 
are dried in the nasal cavities to stimulate the glandular functions. It 
may hv apj)]ie(l by massage, as described above. 

Chemical Caustics. — Chemical caustics are largely replaced by the 
electrocauteiy, though there are instances in which the chemical caustics 
are preferable. The following are recommended : 

Carbolic Acid (95 per cent.). — Where a superficial and diffused cauter- 
ization is desired, as in an unhealthy granulating surface, carbolic acid 
is an ideal caustic agent. It does not penetrate deeply, nor does it 
produce pain. It is also of value in old suppurative ear cases in which 
there is a foul odor and exuberant granulations. The ear should first 
be thoroughly freed from secretions with a cotton-wound probe, and 
the carbolic acid applied afterward. After one minute has elapsed 
alcohol should ])e dropped into the meatus to check the action of the 
carbolic acid and to prevent its action upon the skin of the meatus and 
auricle during its removal. The carbolic acid should be dropped into the 
middle ear with a medicine dropper, care being exercised to avoid getting 
it in contact with the cutaneous surface. 



THE OFFICE EQUIPMENT 57 

Carbolic acid may also be used in the pharynx where a diffused 
superficial caustic action is desired, as in a mild case of granular 
pharyngitis, though in these cases it is usually preferable to puncture 
the follicles or nodules scattered over the pharyngeal wall with the galvano- 
cautery. 

Chromic Acid. — Chromic acid has long been a favorite chemical 
caustic in the nose, throat, and ear, though it has been largely replaced 
by the galvanocautery. A few crystals are engaged upon the end of a 
probe and held over an alcohol or gas blaze to drive off the water of 
crystallization, but not long enough to reduce them to an ash or cinder. 
The bead of acid thus formed is drawn across the area to be cauterized, 
where it rapidly abstracts the water from the tissue and thus destroys or 
cauterizes its superficial layers. 

It may be used in turgescent rhinitis, follicular pharyngitis (granular 
pharyngitis), and in any other condition requiring cauterization. It is 
not as deep in its pentration as is usually desired in either of these condi- 
tions, hence it is not as reliable as the galvanocautery. 

In order to increase its efiiciency, Norval H. Pierce and Max A. Gold- 
stein have devised instruments for its subcutaneous use. The submucous 
method has not, however, appealed strongly to the profession, as the 
galvanocautery is easily and efficiently applied with equally good or 
even better results. 

It should be remembered that chromic acid is quite irritating to the 
kidneys, and may cause albuminuria. Its extensive use is, therefore, 
contraindicated in cases already thus affected. 

Technique. — (a) Local cocaine anesthesia. (&) Puncture the mucous 
membrane at the anterior end of the free border of the inferior turbinated 
body, (c) Introduce a probe or other elevator through the puncture 
and tunnel the substance of the mucous membrane, keeping near the 
periosteum, (d) Introduce the Goldstein concealed probe containing 
the bead of chromic acid into the depth of the tunnel, (e) Uncover 
the bead of chromic acid and withdraw it through the tunnel. This 
cauterizes the wall of the tunnel within the mucous membrane. If 
sloughing does not occur the result is very good. 

Trichloracetic Acid. — This is a valuable chemical caustic agent and 
is generally used in a 20 per cent, solution. It has been employed 
chiefly in tuberculosis of the lar^mx, in conjunction with curettage, and 
in hypertrophied and diseased tonsils after splitting the crypt walls. 

In larjmgeal tuberculosis after the intralaryngeal removal of all the 
tuberculous tissue available by this route the operated area is swabbed with 
a 20 per cent, solution of trichloracetic acid, to destroy any remaining 
tuberculous tissue and to seal up the lymphatic openings to prevent 
the spread of the tuberculous process. 

Kaufmann has recommended the free and deep incision of tlie crypt 
walls of the tonsil, especially of those crypts opening into the supra- 
tonsillar fossa, and applying a 20 per cent, solution of trichloracetic 
acid to the incised surfaces. INIore than one sitting is usually required 
for this purpose. The object of this procedure is to destroy the diseased 



58 THE NOSE AXD ACCESSORY SIXUSES 

epithelial lining of the crypts and to cause cicatricial contraction of the 
substance of the tonsil. In this way the tonsil is reduced in size and its 
non-resistant cryptic epithelium is destroyed. 

The acid applications are very painful for a prolonged period of time. 
This, together with the fact that repeated applications are often necessary, 
renders the procedure an undersirable one. The complete removal 
of the tonsil by dissection is a more certain and desirable procedure, as 
both tonsils may be removed at one sitting. 

The Nitrate of Mercury. — A 10 per cent, solution of the nitrate of 
mercury may be used to cauterize deep sloughing syphilitic ulcers of the 
nose and throat, as it excites healthy granulation, and thereby checks 
the sloughing antl sypliilitic ozcmki. 

Antiseptic and Detergent Solutions. — Cleansing the nose and 
throat with detergent sprays and washes is not as popular a procedure 
now as formerly. Experience has sho^Ti that such applications exert 
little curative action on catarrhal and other diseases. They do, however, 
promote temporary increase in the hyperemia and leukoc}iosis. Such 
solutions also stimulate the constrictor muscle fibers of the swell bodies 
of the turbinals, and thus temporarily reduce the turgescence. The 
antiseptic action is probably but slight and of little value. The three 
useful effects of the antiseptic and alkaline nasal washes are therefore 
as follows: (a) Detergent or cleansing effects. (6) Muscular contrac- 
tion of the interlacing fibers of the swell bodies, (c) Slight promotion 
of the reaction of inflammation. The detergent and stimulating solutions 
recommended are as follows : (1) Seller's solution. (2) Dobel-Pjmchon 
solution. 

(2) IJ.— Powd. sod. bibor. (Squibb). 
Powd. sod. bicarb. (Merck). 

Thymolin Oss 

Glycerin (C. P.) Diss 



First mix and triturate the two salts and place same in one-gallon 
bottle, adding one-half the quantity of glycerin; then let it stand twenty- 
four hours uncorked, with frequent agitations. Next add the remainder 
of the glycerin and continue the agitations for another twenty-four 
hours, with the bottle uncorked as before. Lastly, add the thymolin 
and let stand twenty-four hours. One ounce of this mxture should be 
added to one pint of water, when it is ready for use. 

The solutions may be used with an atomizer, a nasal douche, or 
a syringe. They may also be used as gargles, although the distinctly 
alkaline taste is usually disagreeable to the patient. 

Oily Solutions for Use with a Nebulizer. — Aromatic and antiseptic 
drugs may be added to an oily menstruum and thrown into the respiratory 
tract with a nebulizing device. The action of such mixtures is as an 
emollient or protective agent, and as a stimulant to the mucous glands. 
They also cause contraction of the circular muscle fibers of the arterioles, 
and thereby reduce the congestion. The effects are transient and afford 
relief without exerting a marked curative effect. 



THE OFFICE EQUIPMENT 59 

The following formulse are recommended: 

1. Chloretone inhalant. 

I^. — Chloretone gr. xv 

Camphor gr. xxx 

Menthol gr. xxx 

Oil cinnamon ad TTlv 

Oil petrolatum gij — M. 

2. Acetozone inhalant. 

I^. — Chloretone . . . vij 

Acetozone xv 

Oil petrolatum q. s. ad §ij — M, 

The spray bottles and nebulizing bottles devised by De Vilbiss (Fig. 
17) have proved more satisfactory than any others, as their construction 
is simple and they rarely need repairing or other attention. 

The nasal douche is also a useful device for washing the nasal cavities, 
and is often preferable to the spray tube, as it does not injure the 
epithelium of the nasal mucous membrane. 

The air pressure allowable for spraying the various mucous surfaces 
with De Vilbiss' spray apparatus is as follows : (a) The nasal mucous 
membrane, 4 to 10 pounds. (6) The epipharynx (nasopharynx), 8 to 
20 pounds, (c) The mesopharynx (oropharynx), 10 to 30 pounds. 
{d) The hypopharynx and lar}Tix, 10 to 30 pounds. The air pressure 
needed for the De Vilbiss nebulizing bottles, 10 to 40 pounds. 

The regulating tank elsewhere mentioned is of great value in conjunc- 
tion with the spray and nebulizing tubes. 

Solutions Producing Ischemia. — Solutions producing local blanchmg 
of the mucous membrane are chiefly derived from the suprarenal glands 
of sheep. They produce a powerful contraction of the circular muscle 
fibers of the arteries, which lasts for several minutes. They are on this 
account of diagnostic and therapeutic value. They also reduce the 
amount of primary hemorrhage in operations. 

The following formulae are recommended : 

I^.— Adrenalin chloride 1 to 1000 

I^. — Adrenalin chloride 1 to 2000 

IJ. — Adrenalin chloride 1 to 4000 

It is rarely necessary to use the first formula except when there is a 
great deal of secretion and blood to dilute the solution. If applied to a 
clean mucous membrane the second and third formulae are of sufficient 
strength to contract the vessels. Local ischemia is produced for diag- 
nostic purposes in the various forms of rhinitis and in reducing the 
engorgement of the tissues so as to admit of a view of the nasal cham])ers. 
Adrenalin is also used to check local oozing of blood after operations. 



CHAPTER IV. 

THE ETIOLOGY OF DEF0R:\I1TIES AND DELATIONS OF THE 
SEPTUM NASI. 

"The chief cause of deviations, and probably of many other deformities 
of the septum, is the lack of development of the hard 'palate. Trendel- 
enburg WHS, perhaps, the first to associate the high-arched palate 
with deformity of the septum, but did not, so far as I can learn, consider 
it due to a lack of deyelopment of the maxillary bones. Loewy expresses 
somewhat the same idea, but regards the Gothic, or high-arched palate, 
as of rachitic origin. Ziickerkandl rather scouts this idea and says 
he has been unable to associate rickets with deviated septa, and that it is 
chiefly the lower jaw, not the upper, which exliibits the rachitic influence. 
On the other hand, it is in the every-day experience of us all to find the 
high-arched palate associated with a deviated or otherwise deformed 
septum" (Freeman). Thus in 302 cases of high-arched palate there were 
only twelve where there was no marked deformity of the septum. We 
have 96 per cent, of deformed septa, which shows that there is undoubt- 
edly a very close relationship between the high arch and septal deformities. 
One must not, however, in drawing conclusions as to the relationship 
between the Gothic-arched palate and deformities of the septum, con- 
sider that every high arch is an abnormal one. In studying the skulls 
in the ]Mutter collection. Freeman found that a perfectly straight septum 
was not uncommonly associated with a high arch. This, however, was 
chiefly in dolichocephalic heads, in which, with the high, narrow skull, 
there was associated a high, hard palate, and, in spite of the latter's 
position, the choanre were also very high and narrow. The skulls w^re 
those of non -Europeans, in w4iom, as Ziickerkandl has pointed out, one 
finds deformities of the septum much more infrequent than with us. The 
infant hard palate is of the Gothic type, and anything which interferes 
with the skull and perfect development of the child prevents also the 
development of the hard palate and consequently its descent. Indeed, as 
years go by, the Gothic arch becomes more and more peaked by the 
further development of the alveolar processes and the eruption of the 
teeth. On account of the high position of the palate the septum must 
bend or twist, acconnnodating itself to the boundaries imposed by the 
unyielding framework of the bones with which it articulates. Another 
point in favor of this view is that mentioned by Welcker, that in some 
cases there is a descent of one of the maxillary bones, the other remaining 
high arched, in which case the convexity of the deviation of the septum 
is toward the lower (Freeman). 



DEFORMITIES AND DEVIATIONS OF THE SEPTUM NASI 61 

Eugene S. Talbot has written more extensively and carried on a wider 
range of observations regarding deformities of the facial bones, including 
those of the nose, than perhaps any other investigator. His views are 
briefly presented in the following quotation: 

"Morgagni believed they were due to excessive development of the 
vomer. Trendelenburg held that they were due to a crowding up of a 
high-arched palate, as he had observed the two conditions frequently 
connected. Jarvis has reported 4 cases, all in the same family, and 
suggests they are due to direct hereditary defect, while neurotic or de- 
generate conditions which underlie the building up of the system may 
produce the deflection; direct heredity here, as elsewhere, is rare. 
Schaus' and Welcker's investigations show there is a family development 
of the facial skeleton. Bosworth and others believe that septal defor- 
mities are due to traumatism. 

"According to Bosworth, the clinical history of many of these cases 
affords direct evidence of this, and even in those cases in which the direct 
injury is not testified to, I think it safe to say that an injury has occurred 
which may have been of so slight a character as not to have excited special 
attention at the time of the occurrence. An injury to the nose need not 
necessarily give rise to the immediate development of a notable deformity, 
as in fractures, but it may set up a low grade of morbid action, which, 
going on through a number of years, finally develops a condition by 
which the normal function of the nose is seriously hampered. The 
point on which he lays special emphasis is that the deformity is primarily 
the result of traumatism, and secondarily of a slow inflammatory process 
which results therefrom. 

"Deviation of the nasal septum to one side or the other is the result 
of an unequal development of adjacent bony parts, more especially and 
directly of that of the turbinated bones. It depends largely, if not 
exclusively, upon the development and position of the latter. They, in 
turn, are dependent in great measure upon the development of the facial 
bones, which are modified as the facial angle increases and prognathism 
is lost, the turbinated bones being, as it were, exostosed, not moulded in 
many directions by adjacent parts, encroaching more irregularly upon 
the nasal cavity, as their origins are disturbed or dislocated. Freedom 
of the nasal passages for the transit of respired air is essential. In normal 
respiration the tendency is for both nostrils to share equally. The 
natural consequence is that the vomer, the ossification of which is 
incomplete until puberty, is deflected and occupies, as a rule, nearly a 
midway position between the bony prominences on either side. De- 
flection of the septum therefore is a compensatory arrangement in the 
evolutionary variations of facial development. It is therefore most 
frequent in the higher races, while in the lower its occurrence is markedly 
less. 

"Instability of tissue building is to be expected in neurotics and 
degenerates. It is easy to see how, with such an unstable ])one tissue to 
build upon, the mucous membrane of the nose may undergo atrophy, 
hypertrophy, or adenoid growths resulting in mouth breathing. 



62 THE NOSE AND ACCESSORY SINUSES 

"Total collapse of the outer walls of the nose is frequently observed 
among neurotics and degenerates. This is associated with arrest of 
development of the bones of the face and jaws, deformities of the dental 
arch, contracted chest, round shoulders, husky voice, etc. In most cases 
of this description the nose is very long and thin. The nasal bones 
are excessively developed, and there is marked deflection of the septum. 
Frequently nasal catarrh is present. During inspiration turgescence of 
the swell bodies is produced and nasal breathing is impossible." 

An analysis of the foregoing quotations from Freeman and Talbot gives 
an epitome of some of the theories that have been advanced as to the 
etiology of deformities of the nasal septum. These theories may be 
tabulated as follows: 

1. INIorgagni thought they were due to excessive development of 
the vomer; the vomer crowding upward against the descending perpen- 
dicular plate of the ethmoid caused septal deflection to one side, in order 
to allow of continued development. 

2. Trendelenburg and Freeman think the chief cause of the deflection 
is in the persistent high or Gothic arch of the hard palate. The vomer 
and the perpendicular plate of the ethmoid are thereby crowded and 
deflected in order to find room for further complete development. 

3. Jarvis believes the chief cause is heredity and quotes observations 
in support of this theory. 

4. Schaus and Welcker advance the hypothesis of a faulty develop- 
ment of the facial bones, including those of the nose. 

5. Bosworth argues that traumatism is the chief cause of deflections. 

6. Talbot takes the theory of Schaus and Welcker and carries it still 
farther, and says that malformations of the septum are due to neuroses 
or stigmata of degeneracy, which result in irregular development of the 
facial bones. He believes that the pigeon chest, adenoids, and deformed 
nasal septa are all due to the same neurotic influences, which arrest 
development in some parts while in others there is an increase in the 
development. 

It is difficult to arrive at a final conclusion concerning these theories, 
as data of almost any kind can be found by one who diligently searches 
for it. It is easy to say there is excessive development of the vomer, and 
to report so many thousands of observations on skulls in which this 
theory is substantiated. Trendelenburg and Freeman have satisfied 
themselves that the Gothic arch is the cause. They say the high arch of 
childhood does not descend as it should, and that the space for the 
vomer and the ethmoid plate is thereby encroached upon and deflection 
results. Talbot and others have studied the so-called high arch and find 
that it rarely exists, also that in some instances there is lack of lateral 
development of the superior maxillae, which gives rise to the Gothic arch, 
or what appears to be an abnormally high arch. Actual measurements 
show them to be no higher than normal. Then, too, Talbot claims that 
many hard ])alates which are lower than the average are attended by sep- 
tal deformities. He does not deny that traumatism does in some instances 
account for septal deformities, but he does deny that it is the chief cause 



A CLASSIFICATION OF DEVIATIONS OF THE SEPTUM NASI 63 

of deviations. He believes that consanguineous marriages predispose to 
the neuroses and that facial deformities result therefrom. He holds 
that the facial bones are transitory and more subject to developmental 
influences than most parts of the skeleton, hence are either arrested or 
overdeveloped in those tainted with the stigmata of degeneracy. 

Dr. Talbot's views present the most rational explanation of this 
much mooted question that has yet been ofi^ered. He does not name 
the overdevelopment of a particular bone nor does he claim the failure 
of the palatine arch (roof of the mouth) to descend as being the cause of 
deviations of the septum. If these conditions are present he claims they 
are incidental signs of a neurosis or degeneracy. The factor back of an 
excessive develo'pment of the vomer or of a Gothic or narrow (not high) 
arched palate is also back of the deformed septum. 

In conclusion I will epitomize the etiology of deformities of the nasal 
septum as follows, in the order of their importance: 

(a) Neuroses or stigmata of degeneracy which cause either an arrest 
or an excessive development of the bones of the face, including the nose; 
one of the expressions of the neurosis being deformed septa (Talbot). 

The theories of Trendelenburg, Freeman, Morgagni, Jarvis, Schaus 
and Welcker are swallowed up in that of Talbot. The individual 
theories they advance imperfectly convey the true explanation, while 
Talbot's comprehends them all and strikes at the root of the matter. 

(b) Bosworth's traumatic hypothesis is true as to a certain number of 
cases. That it explains a majority or even a large percentage of them 
is doubtful. 

The phraseology used by Talbot may be objectionable, inasmuch as 
it assumes that there are "stigmata of degeneracy" present in all cases 
not due to traumatism. It would be better perhaps, to say that deflections 
of the septum are usually due to an incoordination in the development 
of the bones of the face, including those of the nose. 



A CLINICAL CLASSIFICATION OF DEVIATIONS OF THE 
SEPTUM NASI. 

Malformation and deviations of the nasal septum may be either 
developmental or traumatic in origin. When developmental, any or 
all portions of the septum may be involved, whereas if it is of trau- 
matic origin the anterior or cartilaginous portion only is affected, except 
in exceptional cases. The point of chief clinical interest, however, is 
in the type and location of the deformity rather than in its origin. Even 
the type and location of the deviation have to a considerable degree 
lost their clinical significance in so far as treatment is concerned, since 
the perfection of the submucous resection of the septum has been 
accomplished, and so many types of septal malformations are found to 
be amenable to it. 

Cartilaginous Deviations. — When the deformity is limited to the 
cartilaginous portion of the septum it is one of three types, viz.: 




64 THE NOSE AXD ACCESSORY SLXUSES 

(a) A deflection of the anterior portion generally known as the columnar 
cartilage (Fig. 22). The antero-inferior border of the cartilage is turned 
outward into the vestibule of the nose and obstructs the respiratory 
passage. This type of deviation is not as serious in its consequences 
as those that obstruct the nasal chamber in the region of the middle tur- 
binated bodv, as it only interferes with the areation of the nasal chamber 
and accessory sinuses, the dramage being unimpaired, except in so far as 
it depends upon the mechanical aid of the 
Fig. 22 air Current in propelling the secretions to 

the epipharjTix. 

(b) An angular deviation in an antero- 
posterior direction is serious in proportion 
to its proximity to the middle turbinal. 
If it is limited to the region of the vesti- 
bule or of the inferior turbinal it is of less 
clinical importance, though its removal is 
still indicated. If it obstructs both the 
middle and the inferior meatuses its re- 
moval is of the greatest importance, as it 
interferes with both the drainage and 
ventilation of the nasal chamber and the 
accessor}^ sinuses of the nose. 
Deviation of the anterior portion (c) A perpendicular deviation of the carti- 

of the septal eartilage, which may be i ^ • i. e 'i.! i.1 iM a" 'xU 

removed through Hajek'. incision by ^^gC Only UlterferCS With the VentllatlOU, Wlth- 

sharp dissection. out blocking the drainage of the secretions, 

except anteriorly, which is inconsiderable. 
Osseous Deviations. — For clinical purposes osseous deviations of the 
septum may be divided into three types: 

(a) A bony ridge or crest along the upper border of the crista nasalis 
and the vomer. The direction of this deformity is backward and 
upward, usually beginning anteriorly about one-half inch from the 
border of the inferior portion of the nasal opening, near the floor of 
the nose. A ridge in this location does not necessarily obstruct the 
normal inspiratory tract (middle and superior meatuses), nor does it 
greatly interfere with the drainage of the secretions. It does, however, 
encroach upon the inferior turbinated body, and thus causes irritation 
of this important physiological organ and produces a sense of stuffiness 
of the nose. It interferes also to some extent with the posterior drain- 
age of the secretions. It also projects to some extent into the respiratory 
pathway and forms a favoraV)le place for the desiccation of the secretions. 
Crusts are, therefore, generally found upon the anterior extremity of the 
ridge, and in blowing the nose become detached, tear the epitlielium, 
and give rise to epistaxis. \Miile the ridge may not cause nasal obstruc- 
tion, it shoukl be removed on account of the mechanical irritation 
of the inferior turbinal and the resulting turgescent and hypertrophic 
rhinitis. 

(b) Tlie perpendicular plate of the ethmoid bone is often convex or 
cup-shaped and impinges upon the middle turbinal upon the side of 



A CLASSIFICATION OF DEVIATIONS OF THE SEPTUM NASI 65 



convexity. This is, perhaps, one of the most serious obstructive lesions 
of the septum, as it obstructs both the drainage and the ventilation of the 
superior meatus, and of the frontal, ethmoidal, and sphenoidal cells. 
Sufficient importance has not been given this type of deviation, hence 
I wish to lay special emphasis upon it. It is this type of deviation, more 
than any other, that gives rise to conditions which eventuate in catarrhal 
and suppurative inflammations of the accessory sinuses. In the first 
place the secretions are retained, undergo decomposition, and impair 
the vitality of the mucous membrane. Infection and inflammatory 
reaction naturally follow. The ostei of the sinuses become closed 
from swelling of the mucosa, and this still further interferes with the 
drainage. Furthermore, the ventilation of the superior meatus and of 
the obstructed sinuses is partially or completely lost, and the de- 
composition of the secretions is thereby encouraged. The oxygen 
of the air within the obstructed sinuses is absorbed and rarefaction 
results. 

The blood of the lining mucous membrane is attracted to the parts by 
the negative pressure thus created, and catarrhal inflammation is 
favored. If, in the course of events, 

active pus-producing microbes, as Fig. 23 

the streptococci, staphylococci, dip- 
lococcus pneumoniae, etc., find 
lodgement there a suppurative in- 
flammation of the sinuses results. 

It is obvious that this type of 
deviation is of the greatest impor- 
tance and that the indications for 
its removal are urgent. 

(c) The combined deviation, in- 
cluding the ridge along the crest 
of the vomer and the convexity 
of the perpendicular plate of the 
ethmoid bone (Fig. 23), is a very 
common type of septal deformity, 
and often calls for correction at 
the hands of the surgeon. The 
indications for operative interfer- 
ence are given under (a) and (6) 
of Osseous Deviations, and need 
not be further discussed here. The indications are obviously more 
urgent than in either the simple ridge or the convex perpendicular plate 
of the ethmoid, as the ill eft'ects of both deviations are to be reckoned 
with. It should be noted that the convexity of the perpendicular plate of 
the ethmoid is usually on the opposite side from the ridge along the 
crest of the vomer, though it may be on the same side. It should also 
be noted that the cartilaginous portion of the septum is deviated with 
the perpendicular plate of the ethmo'd, and should, of course, be in- 
cluded in the operative field. 
5 




A compound deviation of the septum. The 
upper deviation is of the greater clinical im- 
portance, as it blocks the ventilation and drain- 
age of the sinuses. 



66 THE XOSE AND ACCESSORY SIXUSES 

(d) There are still other deformities of the osseous septum, as the so- 
called spurs on the anterior portion, which in reality are composed of 
the crista nasalis and cartilage in combination, though they may be true 
osteomata. 



THE COMPLICATIONS AND SEQUELS OF OBSTRUCTIVE LESIONS 
OF THE SEPTUM. 

A review of the preceding paragraphs naturally leads to the conclusion 
that many of the catarrhal and suppurative inflammations of the nasal 
and accessory sinuses are often due either directly or indirectly to obstruc- 
tive malformations of the septum. 

The whole truth is not expressed in the above statement; nevertheless, 
the deduction is fundamental and should form the working basis in a 
large majority of cases. The etiology of the inflammatory diseases of 
the nose and accessory sinuses is given in Chapter VI. 

The following morbid conditions within the nose and accessory sinuses 
are either directly or indirectly caused, or their course is often largely 
influenced, by a preexisting deviation of the septum: 

1. Acute rhinitis or coryza. 

2. Chronic turgescent rhinitis. 

3. Chronic h}'pertrophic rhinitis. 

4. Chronic h\'perplastic rhinitis. 

5. Acute sinuitis, catarrhal and suppurative. 

6. Chronic sinuitis, catarrhal and suppurative. 

7. Polypoid degeneration of the mucosa of the nose and sinuses. 

8. Atrophic rhinitis. 

It is apparent, therefore, that deviations of the nasal septum should be 
a primary rather than a secondary subject in a systematic text-book on 
diseases of the nose. They are, therefore, herein discussed before taking 
up the consideration of the inflammatory^ diseases which are so largely 
dependent upon them. 

The indications for the correction, or the removal, of obstructive 
deviations of the septum are based upon the following considerations: 

1. If the deviation of the septum does not interfere wdth (a) the func- 
tional activity of the swell bodies of the inferior turbinals, (6) the venti- 
lation of the middle and superior meatuses and the accessory sinuses, 
and (c) the drainage of the same areas it should not be subjected to 
surgical treatment. In other words, deviations of the septum should 
never be corrected simply because they are departures from the median 
line of the nose, but only when they obstruct ventilation and drainage, 
or interfere with the function of the swell bodies. 

2. The positive indications for the correction of deviated septa are 
present when the septum (a) interferes with the normal functional activity 
of the swell bodies, or (6) j^revents the normal ventilation and (c) drain- 
age of the nasal chambers and accessor}^ sinuses. 

If, for instance, a ridge along the crest of the vomer is so prominent 



THE SYMPTOMS OF DEVIATIONS OF THE SEPTUM 67 

as to touch the inferior turbinal, or if it extends forward into the vestibule 
far enough to partially obstruct the inspiratory current of air, and thereby 
produces rarefaction of the air posterior to the obstruction, it should be 
removed. The same is true in reference to anterior angular deflections 
of the cartilaginous septum. 

If the deviation is higher up, in the region of the middle turbinal, and 
interferes with the ventilation of the superior meatus and the accessory 
sinuses draining into it, it should be corrected. 

If a septum is tested by the foregoing standards, with a negative 
result, it should not be subjected to surgical correction, no matter how 
great the deviation or deviations may be. 

If, on the contrary, a septum is tested by the foregoing standards, 
with a positive i;esult, it should be corrected by some surgical procedure. 



THE SYMPTOMS OF DEVIATIONS OF THE SEPTUM. 

The Subjective Symptoms of Obstructive Deviations.— The subjec- 
tive symptoms of nasal obstruction are (a) a sense of fulness, either in the 
lower or upper portion of the nasal chambers, according to the location 
of the deviation. If, for instance, the deviation impinges upon the swell 
body of the inferior turbinal there is a sense of stuffiness or fulness in 
the lower portion of the nose; whereas, if it is in the region of the middle 
turbinal there is a sense of stuffiness or pressure through the bridge of 
the nose between the eyes. 

(6) If the obstruction in the region of the middle turbinal is great 
enough, or has given rise to a catarrhal inflammation in the anterior 
ethmoidal cells, there may be pain at the inner angle of the orbit over 
the lacrymal bone, either with or without pressure. When pain is elicited 
upon pressure in this region, it is very significant of anterior ethmoidal 
inflammation and possibly of the frontal sinus as well. 

(c) Frontal headache is frequently present in high deviations, and is 
most severe in the morning upon awakening. If of ocular origin it dis- 
appears at night and recurs during the day while using the eyes. 

(d) Dizziness or vertigo is sometimes a direct expression of pressure 
or irritation in the ethmoidal and the frontal sinuses. The dizziness 
is often exaggerated, or is produced by stooping forward or suddenly 
rising from the stooping posture, and is present when the eyes are closed. 
Dizziness or vertigo of ocular origin is often relieved when the eyes are 
closed, as the irritation from the light is thereby eliminated. Dizziness 
of nasal origin is aggravated by jarring the body. 

(e) Asthma of reflex nasal origin is sometimes due to intranasal pressure 
and irritation in the middle turbinal and ethmoidal regions. This is 
particularly true when polypi are present. 

(/) The nasal secretions are changed in character and quantity. If a 
chronic catarrhal inflammation of the lower portion of the nasal nuicous 
membrane has developed the secretions are heavier than normal, and 
expulsion is only accomplished by blowing the nose. If the obstruction 



68 



THE NOSE AND ACCESSORY SINUSES 



MMM 










A. Types of non-obstructive septa. a, deviated from the median line; b, normal, straight 
septum in the median line; c, deviation of the lower portion of the septum with a concavity in 
the left nasal chamber, but with compensatory liypertrophy of the left inferior turbinated body. 

B. Types of obstructive septa, a, ridge pressing against the inferior turbinal; b, ridge pressing 
against the left inferior turbinal and a convexity higher up on the right side obstructing the 
olfactory fissure on that side; c, a split .septum causing double obstructive convexity of the septum. 

C. a, an S-shaped septum causing obstruction in the inferior portion of the nasal chamber on 
the right side and the superior portion of the chamber on the left side; b, a liigh, angular devia- 
tion of the septum causing obstruction of the olfactory fissure of the left side. 

D. a, marked deviation of the septum along the crest, the vomer wedged firmly against the 
left infeiior turbinal; 6, abscess or hematoma of the septum obstructing both nasal chambers. 



THE SYMPTOMS OF DEVIATIONS OF THE SEPTUM 



69 



is in the middle turbinal and ethmoidal regions and a simple inflammation 
is present in the ethmoidal cells the secretion is sometimes watery in 
consistency, though it may be mucoid and quite acrid in character. 
Associated signs of this type of secretion are the reddened and irritated 
appearance of the mucosa and a fissure or eczematous eruption of the 
margins of the nostrils and the upper lip. 

(g) Postnasal or epipharyngeal "dropping" is usually complained of. 
The olfactory fissure may be obstructed, and, as the closure prevents 
drainage through the fissure, the secretions flow backward over the middle 
turbinal into the epipharynx. 

(h) Intermittent stenosis is usually present in those cases in which 
there is an anterior deviation which does not completely block the nasal 
passage. The obstruction interferes with the intake of air, and the de- 
scent of the diaphragm acts as the piston valve of a syringe and produces 




A traumatic deformity of the external nose and of the septum. The straight dotted line indicates 
the median line of the nose while the curved one indicates the deviation of the septum. 



rarefaction of the air in the nasal chamber posterior to the obstruction. 
This in turn developes turgescence of the erectile tissue and a temporary 
stenosis. 

(i) Alternating stenosis is another sign of an obstructive lesion in the 
lower portion of the nasal chambers and is due to the same causes given 
in the preceding paragraph. The associated disease is usually turges- 
cent rhinitis. 

The Objective Symptoms of Obstructive Deviations. — (a) The 
appearance of the septum and its relation to the various aspects of the 
outer walls of the nose constitute the most important objective symptoms. 
For example, if the septum is characterized by a ridge on the left side 
opposite the inferior turbinal and by a convexity in the region of the 
middle turbinal on the right side an examination shows the deviations 
and the impingement of the same against the inferior tur])inal on the 
left side and the middle turbinal on the right side (Fig. 24 B, h). Each 



70 THE XOSE AXD ACCESSORY SIXUSES 

case should be carefully examined widi reference to the equal distribu- 
tion of space in the respiratory tract of the nose and with reference to 
its aderjuacy for physiological purposes. The various types of deviations, 
of course, present different pictures upon examination, each having its 
peculiar clinical significance in proportion to the degree of obstruction 
caused by it, and in particular to its proximity to the middle turbinated 
body. 

(6) The presence of pus and dried secretions in the olfactor}' fissure 
between the deviation of the septum and the middle turbinal is sugges- 
tive of the causative relationship of the deviation to the diseased posterior 
ethmoidal sinuses, from which the secretions in all probability flow. 

(c) Hemorrhage or epistaxis is often a sign of a deviated septum, more 
particularly in its lower and anterior portions. A prominent crest pro- 
jecting into the breath way is subjected to an undue exposure to the air 
current and the secretions become dried and adherent to it. Wlien the 
crust is detached, either by blowing or picking the nose, the epithelium 
is torn from the mucous membrane and hemorrhage results. 

(d) External deformity of the nose is often indicative of a corresponding 
deviation of the septum (Fig. 25). 



CHAPTER V. 

THE CHOICE OF SEPTUM OPERATIONS. THE SURGICAL CORREC- 
TION OF OBSTRUCTIVE LESIONS OF THE SEPTUM. 

There is no one method of correcting obstructive deviations or mal- 
formations of the septum nasi. The submucous resection of the septum 
is the most nearly universally applicable, though there are some devia- 
tions in which it can be used with great difficulty, whereas another 
method of surgical procedure can be easily and successfully used. Under 
such conditions poor judgment would be shown in selecting the sub- 
mucous operation. In choosing a surgical procedure a method should 
be adopted that will remove the obstructive lesion of the septum with the 
simplest technique and the least risk to the integrity of the nasal septum. 
The object of the operation should be to establish free drainage and 
ventilation of the nasal chambers and of the accessory nasal sinuses 
(see Etiology of the Inflammatory Diseases of the Nose and Accessory 
Sinuses), rather than to exploit one method of operating over another. 
It will be my endeavor, therefore, to give some general rules to guide 
the surgeon in the proper selection of an operation for the correction or 
removal of obstructive lesions of the nasal septum. 

Cartilaginous Deviations.— When the deviation is limited to the septal 
cartilage other operations than the submucous resection may often be 
chosen to correct it; indeed, they may often be chosen in preference to the 
submucous resection. This is not of universal application, however. 
An extreme angular deviation of the septal cartilage (Fig. 35) is rather 
difficult to correct by the submucous method, and is easily corrected by 
the Sluder operation (Figs. 34, 35 and 36). The Sluder operation is 
practically limited to extreme angular deviations, as stated by its author. 

A cup-shaped deviation may be corrected by the Asch, the Gleason, 
the Watson, the Price-Brown, or the submucous resection operation. The 
simpler of these procedures are the Watson, the Gleason, and the Price- 
Brown operations, and of these the Watson is, perhaps, the more simple. 
The choice of operation will largely depend upon the location of the cup- 
shaped deviation and the thickness of the cartilage surrounding it. If, 
for example, the cartilage anterior to the deviation is extremely thin, or 
has become fibrous from an antecedent chondritis, the triangular flap of 
the Watson operation will not engage against the opposing incised 
cartilage. If, on the other hand, the cartilage anterior to the cup is of the 
usual thickness and texture the Watson operation may be used with 
excellent effect. The cup deviation may also be corrected by the Gleason 
operation if the cartilage below the cup is firm and of the usual thickness. 
The H-incision of Price-Brown is also well adapted to this type 



72 THE NOSE AND ACCESSORY SINUSES 

of deviation. The perpendicular incisions should be made, one anterior 
and the other posterior to the cup, and the intersecting horizontal inci- 
sion through die centre of the cup. The two rectangular flaps thus made 
are forced to the side of the convexity, thereby removing the obstruc- 
tion. The flaps should be held in position with a splint tube or gauze 
dressing for two or more weeks. If for any reason neither of these 
operations is applicable or desirable the removal of the cup-shaped 
cartilage may be accomplished bv submucous resection (Figs. 32, 33, 
37, 38, 39, 44 and 50). 

Compound or S-shaped deviations or compound angular deviations 
of the septal cartilage are peculiarly well adapted to the Kyle operation 
(Figs. 47 and 48). The redundancy of cartilage may be removed with the 
V-shaped file saws at the crest of each convex surface, thus permitting 
the septum to be forced to an upright position in the median line. This 
type of deviation is also easily corrected by the submucous operation 
by the author's method with the swivel knife, and is perhaps more fully 
and surely thus corrected. In this type of deviation there is usually 
little difficulty in elevating the mucoperichondrium, after wdiich the 
cartilage is readily encircled with the swivel knife and removed en masse 
with dressing forceps. 

Simple angular (anteroposterior) deviations and L-shaped angular 
deviations of the septal cartilage are usually very successfully corrected 
by the Watson operation (Figs. 32 and 33), though they are equally well 
adapted to the submucous resection operation with the swivel knife. 

The deviated portion of the cartilaginous septum may be readily 
removed by submucous resection in practically all types of deviations 
except the extreme angular type, and even this may be thus removed. 
It is often preferable, however, to use one of the other methods of 
operating, as they are simpler and almost, if not quite, as satisfactory 
in their results. When, however, the obstructive deviation also involves 
the bony portion of the septum it is often expedient to adopt a method 
of operatmg that will be equally applicable to both the cartilaginous and 
bony deviations. Obstructive deviations usually involve both the cartil- 
aginous and osseous framework of the septum, hence the indications given 
above are not unqualifiedly applicable, except in deviations limited to the 
cartilaginous portion of the septum. One of the chief objections to the 
operations other than the submucous resection is the necessity of wearing 
a dressing or splint in the nose for two or more weeks. This alone 
should often influence the surgeon to elect the submucous operation. 

Osseous Deviations. — As osseous deviations of the septum are nearly 
always associated with one or the other of the types of cartilaginous devia- 
tions already referred to a method of operating should be adopted that will 
successfully remove both the cartilaginous and the bony deviations. The 
operation most universally applicable is the submucous resection. There 
are, however, important exceptions to this rule, notably a simple spur or 
ridge, unattended by other deviation of the septum. Another important 
exception is a deviation limited to the perpendicular plate of the ethmoid, 
which may be successfully reduced with Roe's forceps. 



THE CHOICE OF SEPTUM OPERATIONS 73 

1. A simple spur or ridge may be successfully removed with a saw 
or spokeshave, with less risk to the integrity of the septum than it can 
by submucous resection. If, however, the spur or ridge is accom- 
panied by a deviation of the cartilage or the perpendicular plate of the 
ethmoid it will become necessary to adopt some other method of pro- 
cedure, preferably the submucous resection. 

2. Spurs or Ridges Associated with a Cartilaginous Deviation.- — 
These types of compound deviation may be effectively corrected by first 
removing the ridge with a saw or spokeshave, and subsequently correcting 
the cartilaginous deflection by one of the methods described under carti- 
laginous deviations; or both may be removed at one time by the sub- 
mucous resection operation. 

3. Spurs and Ridges Associated with an Obstructive Deviation of 
the Perpendicular Plate of the Ethmoid. — These types of compound osseous 
deviations may also be corrected by two operations, or by a single opera- 
tion. The ridge or spur may be removed with a saw or spokeshave at 
one time and the deviation of the perpendicular plate of the ethmoid 
at a subsequent time, with Roe's crushing forceps. The submucous 
resection operation is usually preferable, as the operation is completed 
at one sitting, and the results obtained are usually much better than by 
the two operations. 

4. A Simple Deviation Limited to the Perpendicidar Plate of the 
Ethmoid. — ^Two operative procedures are applicable to this type of 
deviation, one the Roe operation and the other the submucous resection 
operation. Of the two operations my own experience is limited to the 
submucous resection, though I can readily conceive the successful applica- 
tion of Roe's method with his crushing forceps. 

As generally practised, the submucous resection operation sacrifices 
more or less of the cartilage, whether it is deviated or not. This is done 
to expose the bony parts to operative interference. I have, in a few cases, 
in which the deviation was limited to the perpendicular plate of the 
ethmoid, made the incision just anterior to the union of the cartilage 
and perpendicular plate of the ethmoid, elevating the mucoperiosteum 
over the ethmoid plate on the side of the incision, then extending the 
incision through the cartilage and elevating the mucoperiosteum on 
the opposite side of the plate, as is done when the Killian incision is 
made. After the elevation was thus completed the deviated portion of 
the perpendicular plate of the ethmoid was removed with the Foster- 
Ballenger forceps (Figs. 65 and 70). While this procedure is rather 
difficult, on account of the inability to see the parts while the forceps are 
in the nasal chamber, it can be done by exercising the proper care in 
instrumentation. The chief difficulty encountered is to avoid the inclu- 
sion of the mucoperiosteum, upon the side of the incision, within tlie 
bite of the forceps. A probe, or flat applicator, introduced into the 
mucoperiosteal pouch, to lift the mucoperiosteal membrane away from 
the bone, will effectually guard the membrane from the forceps. 

Finally, it should be said that the submucous resection operation 
is of the most universal application for the correction of obstructive 



74 THE NOSE AXD ACCESSORY SINUSES 

deviations of the septum, antl that by it the most perfect correction may 
be made. On the other hand, there are many cases in which the 
deviation may be satisfactorily corrected with greater ease, with less 
danger of affecting the integrity of the septum and with less shock to 
the patient. Furthermore, there is always a possibility of producing a 
sunken nose by the removal of a portion of the cartilaginous septum by 
the submucous operation. While the accident has rarely been recorded, 
it has doubtless occurred oftener than is generally known. This 
accident is particularly liable to occur in deviations of traumatic origin, 
as in these cases perichondritis and chondritis sometimes followed the 
injury and destroyed the cartilage, especially along the ridge of the 
nose. If the parts are still further weakened by the removal of cartilage 
the ridge of the nose may fall in. In all cases sufficient cartilage should 
be left along the ridge of the nose to ensure ample support. 



THE SURGICAL CORRECTION OF OBSTRUCTIVE LESIONS OF THE 
NASAL SEPTUM. 

Having first determined that the deviation is an obstructive one (see 
indications) the surgeon should next elect the procedure that will afford 
the greatest amount of correction with the least shock and inconvenience 
to the patient. The type of deviation will have much to do with the 
election of the operative procedure. No hard-and-fast rules can be 
laid down as to the choice of operation, each case being somewhat 
different from all others. 

The following operative methods will, however, with slight variations 
in technique meet nearly all the indications for the surgical correction 
of the various types of septal deviations. 

1. Soft Hypertrophies of the Septum.— Soft hypertrophies of the 
mucous membrane of the septum occur at two points, namely: (a) at 
the anterior portion just opposite to or below the inferior margin of 
the middle turbinated body, and (6) at the posterior end of the vomer. In 
the first instance the enlargement closes the anterior end of the olfac- 
tory fissure and interferes with the proper ventilation of the superior 
meatus and the sinuses draining into it. Its reduction is best accom- 
plished as follows: 

First, induce local anesthesia with a 5 to 10 per cent, solution of 
cocaine applied to the parts with a thin pledget of cotton. 

Second, make one or two linear incisions through the hypertrophied 
tissue with the actual cautery at a bright cherry-red heat (Fig. 26). 

This procedure may be repeated two weeks later if the first application 
was insufficient to reduce the mass. 

In posterior hypertrophy of the septum the same procedure may be 
followed, having first reduced the engorgement of the turbinated bodies 
with a spray of 1 to 2000 solution of adrenalin. 

2. The Removal of Spurs and Ridges with a Saw. — Wlien the septum 
is normally placed, with the exception of a spur or ridge, the obstructive 



OBSTRUCTIVE LESIONS OF THE NASAL SEPTUM 



75 



lesion may be removed with a nasal saw (Fig. 27). If the deviation 
is a pronounced one, it may be preferable to resort to the submucous 
resection operation, as all other deflections can be removed by it at one 
time. 




The reduction of an anterior hypertrophy of the mucous membrane of the septum. (Pynchon.) 
Region of anterior end of the middle turbinal. It is sometimes called the tubercle of the 
septum, o, linear cauterization; 6, cautery electrode making a second linear incision. Apply 
at cherry-red heat. 

Fig. 27 



Bosworth's saw. 



Fig. 28 





Fig. 28. — a, ridge or deformity of the septum; b, the inferior turbinal encroached upon by the 
deviation; c, line of incision to be followed in removing the ridge with a saw. 

Fig. 29. — Showing the method of applying the saw to remove ridges from the septum. 

The technique of the saw operation is as follows : 

(a) Induce local anesthesia over the spur or ridge by the application 
of'pledgets of cotton saturated with a 5 per cent, solution of cocaine. 
After ten minutes remove the cotton, as anesthesia is usually complete 
in this time. 

(b) Introduce the nasal saw beneath'the ridge or spur with its cutting 
edge turned inward and upward, as though it were the intention to saw 
obliquely through the septum (Figs, 28 and 29), 



76 THE NOSE AXD ACCESSORY SIXUSES 

(c) After the saw is engaged in the bony tissue direct it upward (Fig. 
29), parallel with the surface of the septum, until the ridge or spur is 
completely severed from it. 

It is not necessary to make a preliminary incision along the crest of 
the spur or ridge for the purpose of elevating the mucoperiosteum, as 
experience has sIioami that healing takes place quite as quickly and satis- 
factorily when the mucoperiosteum is removed with the bone. Healing 
takes place by granulation and the periosteum is extended by the same 
process of repair over the sawed surface. In a number of cases thus 
operated, and subsequently operated upon by the submucous method, I 
have had little difficulty in elevating the mucoperiosteum over the old 
field of operation. 




Piscliel's collodion dressing, a, a thin pledget of cotton placed over the wound after the re- 
moval of a septal ridge with a saw; b, the collodion being appUed to the cotton with a medicine 
dropper. 

The postoperative dressings should be omitted altogether unless the 
method described by Dr. Pischel is adopted. He first secures absolute 
dryness of the wound, and then applies a thin pledget of cotton over the 
surface and saturates it with an ethereal solution of collodion by means 
of a medicine dropper and allows it to dry in place (Fig. 30). He thus 
hermetically seals the wound with the collodion film and protects it 
from the nasal secretions. The collodion dressing should be left in 
position until it is voluntarily thrown ofl^, which usually occurs in three 
or four days. Subsequent dressings are not required. 

3. The Removal of Spurs and Ridges with the Spokeshave. — The 
spokeshave may be used instead of the saw, tliough it is attended by 
more risk to the integrity of the septum and shock to the patient. 



OBSTRUCTIVE LESIONS OF THE NASAL SEPTUM 77 

The technique is as follows: 
(a) Local anesthesia. 

(6) Make an elliptical incision around the base of the spur or ridge so 
as to prevent tearing of the mucous membrane with the spokeshave. 

(c) Introduce the spokeshave (Fig. 31) into the nostril until its blade 
engages the posterior end of the ridge, and then pull it forward with 
considerable force, again and again if necessary, until it splinters the 
ridge from the septum. The elliptical incision previously made saves 
the mucous membrane from mutilation. 

(d) The dressing may be omitted or the collodion dressing may be used. 
Caution. — So much force is usually required to engage the spokeshave 

that there is danger of fracturing the cribriform plate and causing 
meningitis. 

Another accident which should be taken into consideration is perfora- 
tion of the septum. It is not possible to exercise full control over the 
course of the spokeshave, as it does not cut through the tissue (bony) but 
acts as a wedge. I have sometimes resorted to a little procedure which 
in a measure controls the direction of the splintering, as follows : 

After making the elliptical incision, grooves are made with a saw at the 
base of the ridge on its upper and lower aspects. The grooves guide 
the spokeshave as it comes forward through the bone and thus prevent 
cutting too deeply into the tissue. The grooves weaken the attachment 
of the ridge and render its removal possible with less force. 



Chaleway's spokeshave. 

The Watson Operation. — The Watson operation consists in making 
one or more incisions through the septum and then pushing the projecting 
or deviated portion toward the concave side, the bevelled edges formed 
by the incision retaining the septal flap in its new position. 

Indications. — This operation is suitable for angular deviations of the 
cartilaginous portion of the septum, but is not applicable to bony devia- 
tions or thickenings. When the deviation is simple, that is, when there 
is a single angular deviation extending anteroposteriorly, the incision is 
made from the convex side, beginning at the posterior extremity of the 
deviation and beneath it, extending to its anterior extremity, and thence 
curving forward and upward beyond it, as shown in Fig. 32. 

In compound deviations two incisions are made — one beneatli tlie 
horizontal crest and the other at right angles to the first, and behind the 
perpendicular deviation, as shown in Fig. 33. 

Technique. — (a) Local anesthesia. 

(b) Make the incision or incisions with a short-bladed bistoury. 

(c) Introchice the index finger or a broad, blunt instrument into the 
nose on the side of the septal convexity and force the deviated portion to 
the opposite side. If the single incision is mnde (Fig. 32), force the angu- 



78 



THE NOSE AND ACCESSORY SINUSES 



lar flap to the opposite side along the entire hne of incision. If the double 
incision (Fig. 33) is made, first force the anterior triangular flap (a) 
to the concave side and then force the posterior triangular flap (b) to 
the concave side. The bevelled edges formed in making the incision 
help to hold the flaps in the new position. 

(d) Additional support should be given to the flaps by a tampon on 
the side of the convexity or by a septum tube splint (Fig. 45) for a period 
of from seven to ten days. 

Sluder's Operation. — Dr. Greenfield Sluder has used a modification 
of the Watson operation, with excellent results, and he especially recom- 
mends it in children with extreme angular cartilaginous deflections. 





Fig. 32. — The Watson operation for correcting a simple angular deviation of the cartilaginous 
septum. The angular flap is forced to the opposite or concave side, and held in position with 
a gauze dressing or with a nasal tube. 

Fig. 33. — The Watson operation for a combined horizontal and perpendicular bowing of 
the nasal septum. An incision through the mucous membrane and framework of the septum 
beneath the horizontal convexity, and a secondary perpendicular convexity. The secondary 
inci.sion should unite with the primary one. The anterior triangular flap a thus formed should 
be pushed with the finger to the concave side, and then the posterior flap b should likewise be 
forced to the concave side and held in position with nasal splints for a week or ten days while 
union takes place. 



Technique. — (a) Cocaine anesthesia. 

(6) Make three parallel incisions through the entire thickness of the 
septum parallel with the crest (Figs. 34 and 35). The middle incision 
should extend the whole length of the crest. The other incisions are 
made at the apices of the less acute angles a and b. Two strips of 
cartilage are thus formed, their only attachments being at the anterior 
and posterior extremities. 

(c) Either the upper or lower strip is then forced to the concave side 
with the index finger or a blunt instrument. 

(d) The other strip is likewise displaced to the concave side, thus 
causing the strips to overlap, as shown in Fig. 36. 

(e) An Asch nasal tube is then introduced on the side of convexity 
to hold the strips in position while union takes place, that is for from 
two to three weeks. The tubes are removed and cleansed every two 
to seven days, according to the amount of irritation produced by them. 



OBSTRUCTIVE LESIONS OF THE NASAL SEPTUM 



79 



If the opposed surfaces are curetted before coaptation, union will 
take place more rapidly. Dr. Sluder reports 24 cases, 5 in adults and 
19 in children, without perforation of the septum, all of his cases being 
extreme deflections. 

4. The Gleason Operation. — The election of this operation may be 
made when the septum is bowed or cup-shaped, and without a heavy 

Fig. 34 Fig. 35 




Fig. 34. — Sluder's septum operation. 1, 2 and 3, the lines of incision. 

Fig. 35. — Sectional view of the nose before the Sluder operation. 1, 2, 3, tlie lines of incision 
shown in Fig. 34. 4, the median line of the nose. 

ridge along the crest of the vomer. It 
consists essentially of a U-shaped incision 
extending either entirely through the sep- 
tum and both its mucous coverings, or 
only through the mucous membrane of 
one side and the bone and cartilage, the 
opposite membrane being left intact. 
The incision may be made with a saw, 
though the portion through the cartilage 
may be made with a knife. 

The Technique. — (a) Local anesthesia 
is induced with a 5 to 10 per cent, solu- 
tion of cocaine applied to the mucous 
membrane on both sides of the septum. 

(6) The nasal saw is applied on the 
convex side of the septum at its inferior 
portion, and the incision is carried 
through the septum in an upward di- 
rection, the ends of the saw remaining 
upon the side of convexity while its middle portion passes through to tlie 
concave or opposite side. A U-shaped incision is thus made with a 
tongue-flap suspended between the limbs of the U (Figs. 37 and 38). 




Sectional view of the nose iifter the 
Sluder oi>eration. 1, 2, 3, (he lines of 
incision as shown in Fig. 34. The bands 
of cartilage overlap and should be held 
in position with a nasal tube. 



80 



THE XOSE AXD ACCESSORY SIXUSES 



On account of the low position of the nasal orifice the anterior limb of 
the incision is usually too short. This is obviated by removing the saw 
and re-inserting it through the anterior limb and continuing the incision 
upward, or it may be extended with a knife, as the framework of the 
septum is cartilaginous in this region. 





Tlie Gleasoii ojieration. A tongue flap of the 
deviated portion of the septum. 



Gleason's tongue flap. 



If it is not desirable to extend the incision through the mucous mem- 
brane on the concave side the saw should be directed upward parallel 
with the septal surface on the concave side just beneath the mucous 
membrane. This is not at all difficult, as the mucoperichondrium and 
periosteum usually separate very readily from the cartilage and bone. 
Or the membrane may be first elevated on the concave side 
by the injection of normal salt solution beneath the muco- 
perichondrium and periosteum, thus lifting it away from the 
cartilage and bone. 

(c) Having made the U-shaped incision, the tongue-flap 
should be forced from the convex side through to the con- 
cave side with the finger inserted into the nostril. The 
bevelled edges of the flap and those of the fixed portion of 
the septum engage so as to hold it in its new position on the 
concave side (Fig. 39). The tongue-flap has a tendency to 
spring back into its former position, owing to the elasticity 
of the cartilaginous and bony tissue contained in it, hence 
it is necessary to overcome its resiliency by forcing it as 
far to the concave side as possible, the flap being thus 
fractured at its upper extremity. 
By the foregoing procedure the convex portion of the septum is dis- 
placed toward the side of the greatest nasal space, and the obstructed 
side is opened for freer drainage and ventilation. 

Objections. — One objection to this operation is that it is sometimes 
followed by perforation of the septum. The same is true, however, 
of nearly all other operations which may be substituted for it. 



n, sectional 
view of the 
septum after 
the Gleason 
operation. 



OBSTRUCTIVE LESIONS OF THE NASAL SEPTUM 



81 



Another and more serious objection to it is, that better results can 
often be obtained by the submucous resection of the septum. It is 
obvious that the obstructive portion of the septum can be but partially 
displaced by this operation, whereas, it can be completely removed by 
the submucous resection. 

Dressings. ^ — It may be necessary to insert a nasal tube (Fig. 45) on 
the side of convexity for a day or two to ensure the fixation of the tongue- 
flap in its new position. Otherwise, dressings are not needed. 

5. The Roe Operation. — ^The Roe operation may be used in the same 
type of deviation described under the Watson, Sluder, and Gleason 
operations, and it may also be used to correct the bowing of the septum 
in the region of the middle turbinal, where there is also a ridge on the 
lower portion of the septum, though it is not applicable for the correction 
of an obstruction due to a heavy ridge. Roe has devised special forceps, 
with a male and a female blade (Fig. 40), for this operation. 




The Roe operation, a, schema showing correct method of applying ^the blades of Roe's com- 
minuting forceps; b, schema showing the deviated septiun forced to the concave side; c, schema 
showing the forceps applied to the septum, the male blade over the convexity and the female 
blade over the concavity. 

Technique. — (a) Local anesthesia upon both sides of the septum, 
indeed of the whole nasal mucous membrane, is necessary; or the 
operation may be done under general anesthesia. 

(b) The Roe forceps should be introduced, the male blade into the 
side of convexity and the female blade into the opposite side. By closing 
the forceps blades the convex portion of the septum is forced toward the 
opposite side through the opening of the female blade. The entire area 
of obstruction may be thus fractured and forced toward the concave 
side. 

(c) The fractured portion of the septum should be held in its new 
position with nasal splints, or with strips of bismuth gauze, for two or 
more weeks, or until it becomes fixed in its new position. 

6. The Asch-Meyer Operation. — This operation consists of a crucial 
incision tlirough the cartilaginous portion of the septum, the four tri- 
6 



82 



THE XnSE, AXD ACCESSORY SIXUSES 



angular Haps thus croattMl beino; pushed toward the side of coucavity and 
held in their new position with a Meyer nasal tube (Fig. 45). The opera- 
tion may be used in curved or cup-shaped deviations of the cartilaginous 
septum. In other words, the (ileason, Watson, Sluder, Roe, and Asch- 
Meyer operations are suitable for much the same type of deviated septa. 
I have often included the deviated portion of the perpendicular plate of 
the ethmoid in the field of operation with good residts, and see no 
objection to it, though the operation as originally devised })y Dr. Asch 
was limited to the cartilaginous portion of the septum. 

Technique. — {a) The operation may be performed under local anes- 
thesia, though it is generally preferable to do it under general anesthesia, 
as the shock and pain are otherwise considerable. 




Asch's curved scissors 
Fig. 42 




Asch's straight scissors. 
Fig. 43 




Asc'li's septum force) 



(/;) After cleansing the nasal chambers and the face, the straight Asch 
scissors (button-hole) (Figs. 41, 42 antl 43) should be introduced into the 
nostrils, the narrower blade into the side of convexity and the wider into 
the opposite from three-eighths to one-half of an inch above the floor 
of the nose, and the septum cut through. The Asch angular scissors 
are then introduced and the jxM-pendicular incision made, bisecting the 
middle of the horizontal one. Four triangular flaps are thus made 
(Fig. 44). 

(c) The sej)tuui should next be seized with forceps and fractured by 
rotating it from side to side. It has been my practice to include the 



OBSTRUCTIVE LESIONS OF THE NASAL SEPTUM 



83 




perpendicular plate of the ethmoidal bone in the grasp of the septum 
forceps, as it is nearly always deviated with the cartilaginous portion. 
I have also included the remnants of the ridge left after the sawing opera- 
tion, thus fracturing it (the vomer) 
from its attachment to the maxilla. Fig. 44 ^ 

(d) The index finger is then in- 
serted into the nostril on the side of 
septal convexity and the four trian- 
gular flaps pushed as far as possible 
to the opposite side (Fig. 44), care 
being exercised to fracture the flaps 
at their uncut bases. If this is not 
done the resiliency of the cartilage 
gradually brings them back to their 
original position. 

(e) Severe hemorrhage usually oc- 
curs, but it may be quickly checked 
by the introduction of the Meyer 
nasal tubes. The tubes are prim- 
arily used, however, for the purpose 
of holding the incised and fractured 
septum toward the concave side 
(Fig. 45). The tube selected for the 

convex side should be large enough to force the septum beyond the point 
it is desired to fix it, as it will swing back a little toward its old position 
in spite of all precautions. A smaller tube should be introduced into the 
opposite nostril to exert counterpressure against the septum to check the 
hemorrhage. 

After-treatment. — Both tubes should be left in position for two or 
three days and then removed. A tube one size smaller should then be 
introduced into the side of convexity but none into the opposite side. 
The tubes should be worn for about six weeks, being removed and 



Schema of the Asch operation. The crucial 
incision is made through the de'viated portion 
of the quadrilateral cartilage of the septum, 
thus forming four triangular flaps. The flaps 
are then pushed forcibly to the convex side of 
the septrmi and fractured at their bases, as 
shown by the dotted lines. This is done to 
overcome the resiliency of the cartilage. 




cleansed every alternate day during this jjeriod. Experience has shown 
that the septum graihially swings back to its former position if the tube 
is not worn for about this length of time. 

Objections. — (a) Perforation of the septum sometimes follows the 
operation, (b) The shock attending the operation is often pronounced. 
(c) The inflammatory reaction is sometimes severe, (r/) The presence 



84 



THE XOSE AXD ACCESSORY SINUSES 



of the tube in the nose for six weeks is a source of considerable annoyance. 
(e) The hemorrhage is occasionally severe and difficult to control. 

In spite of these objections, the operation has served, and will doubtless 
continue to serve, a useful purpose, though the submucous resection of 
the sc}>tum bids fair to take its place in most cases. 

7. The Kyle Operation. — The Kyle operation may be used in simple 
and compound curvatures of the thhi portion of the septum. It consists 
in making V-shaped grooves in the septum along the lines of greatest 
convexity, the object being to remove tissue where it is redundant, so that 
the septum may be made straight without overlapping along the lines 
of incision. 



^iiipp^ 



Fetterolf's file saw. 



Fig. 48 





Fig. 47. — Side view of septum after groove is made. 

Fig. 48. — a, sectional view of the septum after the V-shaped iucisioii; b, Kyle's malleable tube 
holding the septum in position. (Kyle's operation.) 




Kyle's malleable tubes. 



Technique. — (a) Local anesthesia of both sides of the septum should 
be induced. 

(6) A linear incision with a small bistoury should be made along the 
lines of convexity. 

(c) The Fetterolf V-shaped file saw (Fig. 4G) should be used along 
the lines of incision until the thickness of the cartilage and bone are 
penetrated (Fig. 47). 



OBSTRUCTIVE LESIONS OF THE NASAL SEPTUM 



85 



(d) The incised septum should then be forced into the median Hne 
by the introduction of Kyle's malleable tubes into either nasal chamber 
(Figs. 48 and 49). 

(e) The after-treatment consists in removing and re-introducing the 
tubes until all tendency of the tissues to return to their former position 



is overcome. 



The Price-Brown Operation. — This method of operating consists of 
making two perpendicular incisions and uniting them by an intersecting 
horizontal incision as shown in Fig. 50. The two rectangular flaps thus 
formed are pushed through to the side of concavity and held in position 




The Price-Brown operation. Two parallel incisions are made, one on either side of the long 
axis of the deviation. An intersecting incision is then made across the long axis of the devia- 
tion. All incisions are made with bevelled edges, so that when the two quadrilateral flaps are 
pushed to the concave side they will engage in the opening as in the Watson and the Gleason 
operations. If this operation is applied to a horizontal deviation (dotted Hues), the two 
parallel incisions would be parallel with the ridge. If bony tissue is involved, the incisions 
should be made with a chisel. 



for a few days or weeks with a nasal splint or dressing upon the side of 
the convexity. The operation is extremely simple, and is especially 
applicable to cup-shaped deviations of the cartilaginous portion of the 
septum. This operation is also applicable to simple perpendicular or 
horizontal angular deviations of the cartilaginous septum, the intersecting 
incision being made across the crest of the angular deviation, as shown 
in Fig. 50. 

Moure's Operation. — Moure's method of straightening the septum 
is especially applicable to those cases in which there is a concavity on one 
side of the septum and a marked thickening or ridge of bone upon the 



86 



THE XOSE AXD ACCESSORY SIXUSES 



opposite side (Fig. 52). This type of deviation is also well suited for 

the submucous operation. 

Technique. — (a) Cocaine anesthesia. 

{b) Remove the ridge with a spokeshave or saw as indicated by 2 in 

Fig. 02. The removal of this ridge of bone materially relieves the 

pressure upon the middle (5) and 
inferior turbinated bodies (4). The 
septum may still crowd too much 
to the convex side, hence Moure ad- 
vises the following procedure to force 
the remaining portion of the septum 
(3) to the opposite side : 

(c) Having removed the ridge, two 
incisions are made as shown in Fig. 
53. One is made below the ridge, 
and the other above and in front of 
it, parallel with the ridge of the nose 
(Fig. 54). The incisions are made 
with specially devised scissors resem- 
bling those of Asch. 

(d) A malleable metal splint is 
then inserted on the side of convexity 

and spread with forceps until the septum is sufficiently forced to the 
opposite side, as shown in Fig. 55. The two incisions permit the septum 
to be forced to the opposite side, where it should l3e held with the 
malleable splint until it becomes fixed in its new position. 

After-treatment. — The splint should be removed in three or four 
days, cleansed, and re-inserted and moulded to the parts. This pro- 
cedure should be repeated every two or three days for from two to five 
weeks, or until firm union has taken place. Should exuberant granula- 
tions form they should be reduced with fused chromic acid crystals. The 
open skeleton tube used by INIoure permits of free respiration and of 
luisal irrigation while it is in place. 




The removal of tlie bony ridge of the 
septum, the preUminary step in Moure's oper- 
ation for the correction of deviations of the 
septum. 



THE SUBMUCOUS RESECTION OF THE SEPTUM. 



1. Apply a 1 to 2()()() solution of adrenalin to the entire surface of both 
sides of the septum on thin pledgets of cotton, which should be left in 
position for from eight to ten minutes. 

2. Local anesthesia: A small cotton-wound probe, slightly moistened 
in water, is dipped into pulverized cocaine and applied about one-half 
minute, by massage, to each side of the septum (Freer). Applications 
should be made every seven minutes. From three to five applications 
induce complete local anesthesia. Occasionally a 20 per cent, solution 
of cocaine applied over the septum widi thin pledgets of cotton acts 
better than the above method. 

3. Blanchiu"; and local anesdiesia beiny; induced, the incision of the 




Fig. 52. — Cross-section of the nose, illustrating certain details of Moure's septum operation. 1, 
the ridge severed with the spokeshave; 2, the incision with the spokeshave; 3, the septinn; 4, 
the inferior turbinate crowded upon by the ridge of the septum; 5, the middle turbinate also 
crowded upon by the de^dated septum. 

Fig. 53. — The incisions of the septum in Moure's operation. 1, the incision along the floor of 
the nose below the septal ridge; 2, the thickened septal ridge; 3, the upper incision through the 
septum being made with Moure's scissors. 



Fig. 54 



Fig. 




Fig. 54. — Making the incisions through the septum with Moure's scissors. 1, Moure'.s scissors; 
2, the septum. 

Fig. 55. — Moure's malleable splint in operation. 1, the septum displaced to the right side of 
the nose; 2, the incision made with Moure's .septum scissors; 3, the outer wall of the nasal splint 
resting against the inferior turbinated body; 3', the inner wall of Moure's nasal splint crowding the 
seiitiim to the right side of the nose. 



88 



THE NOSE AND ACCESSORY SINUSES 



mucoperichondrium upon one side only, by Hajek's or Killian's method, 
is performed (Fig. 5G), though in exceptional cases, Freer's incision is 
preferable (Fig. 57). 

4. The mucoperichondrium (and periosteum) is next elevated upon 
the side of the incision (Figs. 58 and 59). 

5. The incision is next carried through the cartilage, but not through 
the opposite mucoperichondrium (Fig. 60). To carry the incision 
through both membranes results in a permanent perforation, unless one 
side is closed by suture. 



Fig. 56 





Fig. 56. — Incisions for the submucous resection of the septum, a, the Hajek incision; b, the 
Killian incision. 

Fig. 57. — Freer's L-shaped incision; a a, anteroposterior incision along the crest of the ridge; 
a b, perpendicular incision at the anterior end of the horizontal incision. The mucoperiosteima 
should be elevated over the triangular area (a a b) and the curved de\-iation (c c) of the cartilage 
and perpendicular plate of the ethmoid removed, after which the ridge (a a) is removed. This 
incision should be used when the operator is reasonably certain that he cannot avoid mutilating 
the mucous membrane in operating through the Hajek or Killian incision. 



6. Elevate the mucoperichondrium on the opposite side by intro- 
ducing the elevators through the incision in the cartilage (Fig. 61). 

7. Remove such portion of the cartilaginous septum as may be neces- 
sary with the author's swivel knife (Figs. 62 and 63). 

8. Remove the deflected portion of the perpendicular plate of the 
ethmoid bone with the Foster-Ballenger bitmg forceps (Figs. 64 and 65). 

For the removal of the deformed vomer, or ridge, the author uses a 
septum forceps for fracturing it from its attachment to the superior 
maxillae (Fig. 66), though the gouge or Hurd forceps may be used 
(Fig. 67). 



THE SUBMUCOUS RESECTION OF THE SEPTUM 



89 



Thus far Hajek's elevators seem to be best suited for the separation of 
the mucoperichondrium from the cartilage, though smaller and sharper 
elevators are occasionally necessary. 

Additional reasons for adopting a simple armamentarium, requiring 
few introductions for instruments, are the lessened shock and the shorter 
time required for the performance of the operation. These are all- 
important matters from the patient's point of view. The patient 
has a right to expect the best results, with the least shock, in the least 
period of time, and with the greatest safety to his septum. The author 
believes the method herewith illustrated possesses these qualities. 




The elevation of the mucoperichondrium upon the side of the primary incision in the mucous 
membrane. The elevation is begun with a sharp or semisharp elevator and is completed with 
the blunt elevator. 



The successful elevation of the mucoperichondrium depends upon 
several factors, namely: (a) The location of the incision, (b) the degree of 
adhesion of the perichondrium to the cartilage, (c) the care with which 
the incision is made, (d) the instruments used in the elevation, (e) the 
personal equation. 

The location of the incision, whether in the vestibular skin or poste- 
riorly in the mucous membrane (Fig. 56) largely determines the ease witli 
which the membrane is elevated. If made in the skin of the vestibular 
portion of the septum, as practised by Hajek, the elevation is difficult on 
account of the close adherence of the membrane to the underlying hbro- 
cartilage, unless a certain technique is followed. When the incision is 
thus made, injections of Schleich's solution should be made beneath the 



90 



THE XnSK AM) ACCESSORY SIXUSES 




mucojjorichondriuni before makiiif^; the incision. This separates or par- 
tially separates the jjerichondriuin from the fibrocartilage and renders 
the remaining steps of the elevation comparatively easy. Indeed, if this 
technique is followetl the membrane is more quickly elevated than by 
any other method in any location. 

If Killian's incision is made in the mucous membrane just posterior 
to the vestibular skin, considerable difficulty is sometimes encountered 

in starting the elevation, many min- 
utes often being consimied in this 
step. The difficulty is not so much 
on account of the close adhesion of 
the perichondrium to the cartilage, 
as the faulty technique employed. 
The mucous membrane is rather 
loosely adherent to the perichon- 
drium and the operator failing to 
engage the elevator beneath the 
perichondrium proceeds to separate 
^1 v( the mucous membrane from the 

mJ (i\ perichondrium. The elevation pro- 

li/ O )m ceeds slowly and the operator 

wrongly infers that the mucoperi- 
chondrium is bound down by an 
inflammatory exudate. The so- 
called adhesions are exceptional 
rather than the rule. When the 
elevation proceeds with difficulty the membrane should be pushed away, 
the wound dried with a cotton-wound applicator, and the denuded sur- 
face examined. If it presents a velvety pink surface, the perichondrium 
is still attached to the cartilage. If it presents a smooth, white, glisten- 
ing surface, the elevator is beneath the perichondrium and the elevation 
may be safely continued. An experience in about 300 submucous resec- 
tions has taught me that the perichondrium is less tightly adherent in 
certain areas than others. This knowledge has led me to seek the path 
of least resistance, namely, along the ridge of the nose. In other words, 
the elevation should be begim at the upper end of the incision and con- 
tinued beneath the I'idge of the nose for the distance of an inch or more 
before attempting to elevate the lower portion. Having thus success- 
fully begun the elevation do not make the mistake of using the tip of the 
elevator to complete it. The tip of the elevator is only of use in starting 
the elevation. After this is accomplished the long edge of the instru- 
ment should be used to coinplete it. It is ol)vious that the tip is more 
liable to perforate the mucoperichondrium than is the long, dull edge 
of the elevator. The perichondrium and periosteum may be readily 
stripped from the underlying framework of the septum, while they are 
dissected from it with difficulty and hazard. This is a fact that should 
l^ understood, for if it is not understood, operators will tear the mem- 
brane in endeavoring to elevate it with the tip of the instrument. 



Elevation of the mucoperichondnum by 
Beck's method. 



THE SUBMUCOUS RESECTION OF THE SEPTUM 91 

Fig. 60 




The mucoperichondrium being elevated, the cartilage is incised, care being exercised to avoid 
perforating the mucoperichondrium upon the opposite side of the septum. The finger is intro- 
duced into the opposite nasal chamber to detect the point of the knife the moment it penetrates 
the substance of the septal cartilage. The incision should be slowly and delicately performed. 
Should the mucous membrane upon the opposite side of the septum be incised, it will be neces- 
sary to suture it to prevent permanent perforation of the septum. 



Fig. 61 




The cartilage being incised, the mucoitericl 
elevated. Tlie elevation is begun with a sh 
blunt elevator. 



92 THE NOSE AXD ACCESSORY SINUSES 

Fig. 62 




I 



The mucoperichondria being elevated on both sides of the septum over the area of the obstruc- 
tive deviation, the cartilage is removed with the swivel knife. The tines or prongs of the knife 
aie placed astride the cartilage and between the mucoperichondria (a Foster septmn speculum 
(Fig. 78) being used to separate tlie mucoperichondria if desired). The swivel knife may be 
engaged at either the inferior or the superior aspect of the cartilage, according to the preference 
of the operator. The anterior portion of the cartilage is sometimes fibrous, and the incision 
should then be started with a knife or scissors. If the swivel knife is engaged in the inferior por- 
tion of the cartilage, as shown in this illustration, it should be pushed along the crests of the 
spina nasalis and vomer to the junction of the perpendicular plate of the ethmoid and the vomer. 
The knife should then be drawn forward and upward along the antero-inferior border of the 
perpendicular plate of the ethmoid, and thence downward and forward to the superior end of 
the incision in the cartilage. The cartilage of the septum is thus completely encircled and ready 
to be removed. The advantages of this method of removing the cartilage are the simplicity of 
the procedure, the short time consumed, and the preservation of the specimen for inspection. 

Fig. 63 




The cartilage having been excised submucously with the swivel knife, 
niucoperichondrial pouch with dressing forceps. 



removed from the 



THE SUBMUCOUS RESECTION OF THE SEPTUM 



93 



Another point in the technique of the elevation of the mucoperichon- 
drium is how to elevate beyond a perpendicular angular deviation. 




Showing the mucoperichondrial pouch after the removal of the cartilage. The bony crest of 
the vomer is shown in the bottom of the pouch, while deep in the pouch is shown the perpen- 
dicular plate of the etlimoid extending upward from the crest of the vomer. This should be 
removed with the Ballenger-Foster forceps, as shown in Fig. 65. 




The removal of the perpendicular i)!ate of the etlunoid hone with the Fostei-BallcMjier for- 
ceps, a, the area of cartilage previously removed with the swivel knife; b, the area of bone 
removed with a single bite of the forceps. Two or three bites remove nearly all of the perpen- 
dicular plate without removing the forceps from between the mucoperiostia. This is a matter 
of some importance, as each iiitnidtii'tidti of an instruinont oiuhmgors flio iiilogiity of the mucous 
membrane. 



Curved elevators have been devised for this purpose, and tliey may be 
used if the operator desires. My practice has been to spring the devi- 



94 



THE XOSE AXD ACCESSORY SIXUSES 



atcd cartilage to the concave side, thus rendering it straight, and then to 
proceed witli a blunt, heavy elevator. I have also taken advantage of the 
resilience of the tip of the nose, bending it to one side until the elevator 
was parallel with the surface of the cartilage posterior to the crest of the 
deviation. By taking advantage of the flexibility of the cartilage and 
even of the same quality in the perpendicular plate of the ethmoid I 
have been able to elevate the mucoperichondrium with ease when it 
appeared to be a difficult procedure. 

Schleich's solution may be injected prior to making the Killian incision, 
thus facilitating the elevation. 




I 



The author's method of remov-ing the ridge of bone in the submucous resection of the sept uiu. 
a, the septum forceps grasping the ridge, the blades being external to the mucous membranes. 
The forceps is rotated on its longitudinal axis as in the Asch operation, thus fracturing the 
vomer from its lower attachment. During the fracturing process the mucoperiosteum below the 
ridge becomes detached from the bone, b, the area of cartilage and perpendicular plate of the 
ethmoid previously removed. The mucous membrane is shown removed, though this is not 
actually done in the operation. Having fractured the ridge (vomer) from its attachment at the 
floor of the nose dressing forceps are introduced into the mucoperichondrial pouch, i. e., between 
the elevated membranes, the bony ridge seized and removed through the anterior Killian or 
Hajek incision. A Httle gentle manipulation may be necessary to completely detach the bone. 
This method is only adapted to adults in whom ossification is complete. As the cartilage and 
bone between the vomer and cranial plate is removed the fracture of the vomer does not transmit 
shock to the brain. 



Only when these facts are fully comprehended and observed will the 
submucous operation be performed with ease and success. 

The author's swivel knife is made in two parts — the handle and 
the prongs, and the swivel blade. It is only used to remove the 
cartilaginous portion of the septum, which it does in one piece. The 
illustrations show the two widths of the swivel knife (Fig. 69). The 
wider one is for extreme deviations of the septal cartilage, and for the 
removal of part or all of the inferior turbinated body. The swivel 
knife is swung on pivots between the prong tips, between which it freely 
swings in a complete circle. The direction of the cutting edge (concave 
edge) is controlled by the resistance of the cartilage through which it pas.ses. 



i 



THE SUBMUCOUS RESECTION OF THE SEPTUM 



95 



In the submucous operation the cartilage is removed en masse, one minute 
rarely being required for this purpose. The operation is thus shortened, 
the number of instrumentations considerably diminished, and the speci- 




The removal of the thickened crest of the vomer with the author's V-shaped gouge. The 
gouge should be tapped with a m^allet, and when well engaged, prying movements will splinter 
the bone. The whole of the thickened or deviated crest may be thus removed in one or more 
pieces. If the mucoperiosteum is adherent to the vomer beneath the deviated crest, it will sepa- 
rate as the bone sphnters from its attachment to the intermaxillary bone. Should some por- 
tions of the deviated bone remain after the use of the gouge, they may be removed with bone 
forceps (Fig. 75). 

Fig. 68 



This shows the principle underlying the use of the semisharp and dull elevators in the subcu- 
taneous resection of the septum. The first figure shows the semisharp elevator with its edge 
against tlie mucoperichondrium (a b). It is obvious that a false move would cut through the peri- 
chondrium and cause a perforation. The chief use of the sharp and semisharp elevator should 
be limited to starting the elevation at the original point of incision and at points where there 
i;! inflanimatory adhe.'^ion. The second figure shows the dull elevator lifting the mucoperichon- 
diium alioad of its tip or dull edge. As the mucoperichondnum and mucoperiosteum of the 
seiituin onlinarily strip readily, they may be elevated rapidly and safely with the blunt elevator. 



Fig. 6 



iiiiiiiiiiiiinifflimffliiiiffliiii||pipipiimimr"wm|,. 



The author'.s swi\el cartilage knife. 



96 



rjIE NOSE AXD ACCESSORY SIXUSES 



men is preserved for inspection. The swivel knife renders the sub- 
mucous resection of the nasal septum, especially the cartilaginous 
portion, simple and attractive. The use of the instrument is so easily 
mastered that a novice should feel at home with it after the first trial. 
It is under the absolute control of the operator. 




Foster-Ballcnger perpendicular plate bone forceps. 
Fig. 71 



'=3Efci 



Hajek-lialleiiger umcupeiicliuuaiia elevators. 
Fig. 72 



|-| ... 



!ii!i!ii 



The author's mucosa knife. 
Fig. 73 




Hajek's septiun gouge. 



— , ,^_'ii'"" iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiniiiiiiinm^ 

F.A.HfiPDr8 co.cHicneo 
The author's septuni gouge. 

Some writers have stated that the swivel knife is objectionable because 
it Is liable to tear the mucous membrane. Such a statement can mean 
but one of two things, namely, (a) that the operator is extremely 
awkward, or (/;) that he failed to sufficiently elevate the membrane. 



THE SUBMUCOUS RESECTION OF THE SEPTUM 



97 



Any operator with but a moderate experience with the subcutaneous 
resection of the septum knows that it is next to impossible to tear the 
mucous membrane with the swivel knife if the mucoperichondrium is 
previously elevated over the entire operative field. 

One writer makes the claim that the swivel knife is not an exact instru- 
ment — is not under the exact control of the operator. This is a 
mistaken idea and is not based upon personal experience, but is a theo- 
retical deduction. As a matter of fact it is one of the most exact and 



Fig. 76 





Kurd's bone septum forceps. 
Fig. 77 




Allen's nasal speculum. 
Fig. 78 



F.A.HARDYXCO, 
CHICAGO, 




Beck's operative nasal speculum. 



Ballenger-Foster septum specuh 



easily controlled instruments used in this operation. It cuts cartilage 
with l)ut slight resistance, and may be directed with the greatest pre- 
cision so as to encircle the amount of cartilage it is necessary to remove. 
It is stated in the fourth edition of Kyle's Text-hook on the Diseases 
of the Nose and Throat that the swivel knife was first suggested by Dr. 
N. H. Pierce and introduced by Dr. W. L. Ballenger. This is erro- 
neous (without intention to misstate), as neither Dr. Pierce nor anyone 
else suggested the idea of the swivel knife to me. The idea occurred to 
7 



98 



THE XOSE AXD ACCESSORY SIXUSES 



me when I first saw Killian's septum knife or spokeshave, which has a 
fixed bhide between the prongs of the instrument. The thought 
occurred to me then that if the blade were pivoted at its edge to allow 
it to swing between the tines or prongs of the instrument, it could be 
made to encircle the cartilage and remove it en masse. I immediately 
had the instrument made bv Mr. Kratz- 
miiller, of F. A. Hardy & Co., and it has 
since then been kindly received by rhinol- 
ogists in every country where rhinology 
is practised. 

Author's differ as to the re-formation 
of the cartilage of the septum after its re- 
moval. According to J. C. Beck (Figs. 
80 and 81), no cartilage cells were found 
in the tissues after a lapse of two and one-half years. The removed 
cartilage was replaced by dense fibrous tissue. Freer, on the other 
hand, claims that the cartilage re-forms, especially in the younger sub- 
jects. 




json's nasal sponge splint 



Fig. 80 






^^^?cr?^^^^^^^^^^ .j^ 




^^^^^^^te^is^^ij^i^.^^ -'^ 


I^^^^SIIlIM ' 


^^^^^^Pl 



Section of septum two and one-half years after a submucous resection of bone and cartilage 
shows no regeneration of either bone or cartilage, but is replaced by a dense fibrous tissue. Age 
forty-seven years. (Specimen kindly loaned by Dr. J. C. Beck.) 



After-treatment.— x\fter all of the obstructive cartilaginous an(l bony 
frame of the se])tuin has been removed, a Simpson sponge tent (Fig. 79) 
should be introduced into each nasal chamber to force the mucous mem- 
branes together. A few drops of sterile water should be instilled into 
the ends of the tents to cause them to swell and compress the septum, 
(iauze impregnated with subnitrate of bismuth powder may be used 
instead of the tents, or a thin rubber finger-stall may be placed in each 



THE SUBMUCOUS RESECTION OF THE SEPTUM 



99 



nasal chamber and packed with gauze (Casselberry) . The Simpson 
sponge-tents should be removed in from twenty-four to forty-eight 
hours after the operation. They may be removed layer by layer and a 
thin lamina left over the line of incision for a day longer. If the mucous 
membrane along the line of incision is not torn, healing should take 
place by first intention. If the mucoperichondrium is torn or otherwise 
destroyed at any point, healing will occur by granulation and will require 
from five to fourteen days, according to the area of mucous membrane 
destroyed. Th's constitutes the chief objection to the extensive Freer 
incision. The flap is large and retracts and leaves a large surface to 
heal by granulation. 

Fig. 81 




Fig. 80, only higher power. 



General Remarks.— The Asch, Watson, and Gleason spokeshave, the 
sawing operation of Bosworth, and the submucous resection of the septum 
may be followed by perforation of the septum. The Asch and Gleason 
spokeshave, the Moure and the submucous resection operations are more 
liable to this accident than the sawing operation, the Sluder, Roe, and 
Watson operations. The submucous resection of the septum, if carefully 
carried out, is no more liable to perforate than either of the other opera- 
tions. I am partial to this operation, because by it any type of devia- 
tion of any portion of the septum may be removed, whereas, the other 
methods of operating are only applicable to certain types of deviations. 
In view of the difficulties encountered in the performance of the sub- 
mucous resection of the septum, the average operator should carefully 
consider the simpler methods of correcting the obstructive deviation 
before resorting to the submucous resection operation. The submucous 
resection of the septum is a major operation, and should be reserved for 

LOfC 



100 THE NOSE AXD ACCESSORY SINUSES 

those cases which cannot be corrected by the simpler operations. 
Unfortunately, a majority of the cases requiring the removal of septal 
deviations cannot be adequately corrected by any operation other than 
the submucous resection. It is often better to correct the deviation in the 
region of the middle turbinated body, even at the risk of leaving a per- 
manent perforation of the septum, than it is to do a simpler operation 
which but partially overcomes the obstructive lesion. If further expe- 
rience demonstrates the wisdom of removing the middle turbinal and the 
ethmoidal cells rather than the high deviations of the septum, the indica- 
tions for the submucous resection of the septum will be greatly modified. 
In view of the difficult technique and of the possible complications 
attending the submucous resection of the upper portion of the septum, 
I am still endeavoring to find a method of procedure attended by less 
technical difficulties and fewer complications and sequels. Notwith- 
standing this fact, I am of the opinion that, as we now understand 
nasal and sinus diseases, the submucous resection of the septum should 
be the operation of choice in a majority of the cases of obstructive 
deviations of the septum. 



PERFORATION OF THE SEPTUM. 

Etiology. — The causes of perforation of the septum may be divided 
into (a) congenital, (b) chronic granuloma, (c) traumatic, (d) acute 
infection, and (e) atrophic or perforating ulcer. 

(a) Congenital perforation is extremely rare, Zuckerkandl having 
reported a few cases. 

(h) Chronic granulomata, as syphilis, tubercle, and lupus, are respon- 
sible for a considerable percentage of the cases, some authors attributing 
as high as 50 to 60 per cent, to syphilis alone. In my experience the 
percentage due to syphilis is much less than this; syphilis is not, however, 
as common in this as in some other countries. Syphilitic perforations 
almost always include the bony portion of the septum, whereas, tubercle 
and lupus are limited to the cartilaginous portion. The tuberculous 
and lupous origin of the perforating ulcer may be determined by finding 
the tubercle bacilli, or tuberculous histological changes in the tissues. 
A slow but a reliable method of demonstrating the tuberculous process 
is to inject a guinea pig with some of the tissue from the ulcer. Six weeks 
later hold a postmortem on the pig and note the presence or absence of 
a tuberculous process. 

(c) Traumatic perforations may include any portion of the septum, 
as they are usually due to surgical procedures, though they may be due 
to accidental violence and to picking the nose with the finger nail. 

(d) Acute infectious diseases, as diphtheria, scarlet fever, typhoid 
fever, phlegmonous abscess, etc., may result in perforations. 

(e) Atrophic or perforating ulcer of the septum is probably the most 
common type of perforation. Several conditions contribute to the 
etiology of this type of perforating ulcer. An anterior spur or deviation 



PERFORATION OF THE SEPTUM 



101 



of the cartilaginous portion of the septum is usually present, and on 
account of its projection into the field of the inspiratory current of air, 
it is subjected to constant mechanical irritation and to the desiccation 
of the secretions which constantly accumulate upon it. The ciliated 
columnar epithelium undergoes retrograde changes to a less specialized 
type of epithelium (pavement epithelium). The dust and other foreign 
substances in the aifalso irritate the epithelium and mucous membrane. 




The cartilage (c) being removed with the author's single-tined swivel knife in Goldstein's 
plastic septum operation. 

The crusts' thus formed in this area become adherent, and are forcibly 
blown or picked off with the finger nail, the epithelium coming away 
with them. Hemorrhagic deposits in the mucous membrane occur, and 
epistaxis is of frequent occurrence. The retrograde process continues 
until the entire thickness of the septum is destroyed. Infection plays 
a part in the foregoing process. 

Symptoms. — ^The symptoms of perforation of the septum vary with 
the size, cause, and location of the perforation. A small anterior per- 
foration sometimes gives rise to a musical whistling sound, whereas a 



The author's mucosa swivel knife. 



large one does not. If the perforation is associated with a prominent 
bony spur, there may be a sense of stuffiness in the nose. Crusts, if of 
large size, may cause the feeling of a foreign body in the nose, and, if 
forcibly blown or picked off, may give rise to nasal hemorrhage. Re- 
peated epistaxis should arouse suspicion of a perforating ulcer. Syphil- 
itic ulceration is usually accompanied by an offensive necrotic odor. 
Many cases will progress to complete perforation without the patient's 
knowledge of the fact. 



102 



THE NOSE AND ACCESSORY SIX USES 



Treatment. — If seen in the ulcerative stage, before perforation, the 
progress of the local retrograde changes may be checked by appropriate 




Fig. 84. — Sliowng the method of outlining the flap with the author's swivel mucosa knife for 
the closure of a perforation of the septum. 

Fig. 85. — f, the plastic flap sutured in the perforation; c, the pedicle of the plastic flap; b, the 
denuded area from which the plastic flap is removed heals by granulation; d, the edge of the 
plastic flap between the mucoperichondria of the .septum. 



Fig. 86 




Schema of Hazletine's plastic operation for the closure of i)erforations of the septum, ab, 
incision in front of the perforation; ee, the incision posterior to the perforation on the oppo.site 
side of the septum; cc, the freshened edges of the perforation. 



PERFORATION OF THE SEPTUM 



103 



local cleansing and antiseptic washes and ointments, or, if due to syphilis, 
by the administration of the proper remedies for this disease. When 
the perforation is complete, little can be done except in a surgical way. 
Large perforations are not, however, amenable to surgical closure. 
Small ones may often be closed by proper plastic surgical procedures. 

Goldstein's Plastic Flap Operation. — Dr. M. A. Goldstein has suggested 
and successfully used a plastic flap of mucous membrane turned into 
the opening and inserted and sutured between the elevated membranes 
of the two sides of the septum. 




Detaifof Fig. 86, showing the opposite side of the 
septum. 



Detail of Fig. 86. a, the denuded cartilage 
after the plastic flap is sutured (/ /). 



Technique. — (a) Cocaine anesthesia. 

(6) The rim or edge of the perforation is freshened by paring off the 
epithelium and mucous membrane. 

(c) The mucoperichondrium is then elevated for a distance of one- 
half inch around the edge of the perforation. 

(d) A ring of cartilage is then resected for one-eighth to one-fourth 
inch from the edge of the perforation, the author's single-tined swivel 
knife being used for the purpose (Fig. 82) . 

(e) A mucous membrane flap, the area of whicli is considerably larger 
than the perforation, is then dissected from tlie most convenient surface 



104 THE NOSE AND ACCESSORY SINUSES 

of the septum and turned into the perforation and tucked between the 
elevated membranes around the perforation. I have devised a traihng 
swivel knife (Fig. S'3) for outlining this flap. The method of using it is 
is showai in Fig. 84. 

(/) "NMien the pedicled flap is in position (Fig. 85) three or four stitches 
hold it in position. One surface is covered by epithelium, while the 
other is left to heal by granulation from the edges of the closed perfora- 
tion. 

Hazletine's Plastic Operation. — This operation is also only suited to 
small perforations. It is simpler than the pedicled flap operation, and 
appears to be a more satisfactory procedure. 

Technique. — (a) Cocaine anesthesia. 

(b) Freshen the edges of the perforation and elevate the mucoperi- 
chondrium, as in the submucous resection operation. 

(c) Make a long curved incision (Fig. 86 b h) through the mucoperi- 
chondrium one-fourth to one-half inch anterior to the perforation, as 
shown in Fig. 86. 

(d) ^Nlake a long curved incision {e e) through the mucoperichondrium 
of the opposite side of the septum, one-fourth to one-half inch posterior 
to the perforation. 

(e) Suture the anterior flap to the freshened posterior edge of the mu- 
cous membrane of the perforation (Fig. 88), and the posterior flap on 
the opposite side of the septum to the freshened anterior edge of the 
membrane of the perforation, as showTi in Fig. 87. The areas a and a 
heal by granulation. 

(/) Remove the sutures in twenty-four to thirty-six hours. By this 
procedure the perforation is covered by two mucous membranes, and, 
the lines of suture not being apposite, closure of the perforation follows. 



CHAPTJEK VI. 

THE ETIOLOGY OF INFLAMMATORY DISEASES OF THE NOSE 
AND ACCESSORY SINUSES. 

INFLAMMATION. 

Before discussing the causes of inflammation, it will be well to define 
inflammation. 

Acute InJBammation. — Acute inflammation is a threefold reaction 
excited by the presence of certain noxa, or irritant material, in the tissues. 
The noxa or irritant is usually a pathogenic microorganism and its 
toxin, or it may be of chemical or traumatic origin. When of chemical 
or traumatic origin the irritant primarily consists of the dead or broken- 
down cells of the tissues. 

Dead or broken-down cells, when present in the tissues in excess, be- 
come foreign bodies, and, as such, a reaction of the living cells is excited 
for the purpose of eliminating them from the body. Furthermore, the 
dead cells in the process of disintegration give off a ferment or chemical 
substance which also excites a reaction, the purpose of which is to free 
the tissues of its presence. The reaction thus far excited is directly 
traceable to the presence of dead and disintegrating tissue cells. Or- 
dinarily, after a short time, a secondary irritant gains entrance to the 
injured tissues and becomes the more important factor in the reactionary 
process. That is, pathogenic bacteria infect the impaired tissues so 
that in nearly every acute inflammatory process, whether it is due to 
primary infection or to chemical or mechanical trauma, pathogenic 
microorganisms must be regarded as the paramount exciting or noxious 
agent causing the reaction of inflammation. 

The reaction of inflammation is, therefore, an increased physiological 
activity of the living tissues of the body for the purpose of disposing of a 
noxious or irritant substance or organism that has invaded them in 
excess of the normal quantities. 

The reaction of acute inflammation is a threefold process, namely: 

1. Increased hyperemia. 

2. Increased nutrition (increased resistance). 

3. Increased leukocytosis. 

1. Increased hyperemia is a constant and important reaction, as 
through it the cells are provided with the extra nutrition they need under 
conditions of stress. The increased blood supply also stimulates and 
facilitates the increased migration of leukocytes, and it flushes the 
poisoned area and dilutes the noxious substance, and tlius reduces the 
intensity of the irritation. The hyperemia is nearly always passive in 



106 THE NOSE AXB ACCESSORY SINUSES 

type. It has been demonstrated that passive hyperemia is more potent 
in overcoming bacterial irritation than active hyperemia, though active 
hyperemia, when well established, is also very efficient. 

2. Increased nutrition of the tissues is promoted by the hyperemia 
for obvious reasons. They are under stress because of the presence of 
noxious substances, and need extra nutritional facilities. Their vital 
force, or resistance, is not equal to the emergency placed upon them, 
and upon their resistance depends the issue of the warfare. Their means 
of defence may be characterized as twofold, namely: (a) Their ability 
to envelop and digest microorganisms, and (6) their ability to produce 
and emit a biochemical substance or ferment, the purpose of which is 
to weaken or destroy their foe. This all requires increased nutrition 
(blood), which begets increased powers of resistance. 

If the nutrition is not adequate for these purposes, the microorganisms 
and their toxin, or l)iochemical irritant, may cause destructive and what 
we are accustomed to call pathological changes in the tissues. 

3. Increased leukocytosis is also an important reaction of inflamma- 
tion. Wliile the function and modes of activity of the leukocytes is not 
fully understood, it has been fairly well demonstrated that the poly- 
morphonuclear leukocytes envelop and destroy bacteria, while the 
lymphocytes envelop and destroy broken-down cells. Other cells, as the 
fibroblasts, also participate in these functions under certain conditions. 
I have not time to enter into a discussion of all the processes included in 
the reaction of inflammation, and only desire briefly to suggest the more 
important and well-known processes in order to prepare our minds for 
a clearer understanding of the etiology of the inflammatory diseases of 
the nose and accessory sinuses. 

Quality of Reaction. — Parenthetically, I wish to add one additional 
statement concerning the adequacy of the reaction of inflammation. 
According to Adami the reaction of inflammation may be of three types : 

1. Adequate reaction. 

2. Inadequate reaction. 

3. Excessive reaction. 

The reaction is usually inadequate. That is, the increased hyperemia, 
cell nutrition, and migration of leukocytes is insufficient to dispose of 
the pathogenic microorganisms before they have caused considerable 
damage to the tissues. It follows, therefore, that in the treatment of 
inflammatory diseases the reaction of inflammation should be promoted 
rather than diminished. By so aiding the defensive and offensive 
activities of the tissues, the bacteria, their toxins, and the }>roken-down 
tissue cells may be speedily removed and a cure effected. 

Inflammation Affecting Mucous Surfaces. — Adami says: "The main 
distinguishing feature of the mucous surface is the presence there of a 
layer of mucous cells of a glandular type, capable, when stimulated, 
of forming and discharging relatively large amounts of mucin. The 
hyperemia, the exudation of serum, the migration of leukocytes, all these 
occur in the submucous layer just as in the subserous layers. The changes 
in the reaction are due solely to the interposition of this layer of mucous 



INFLAMMATION 107 

cells. There is, in the first place, a more definite basement substance 
interposing a certain amount of resistance to surface exudation. The 
layer of mucous cells is more complicated, and although the fully devel- 
oped cells may be discharged, they are apt to remain relatively undif- 
ferentiated 'mother cells' at the base; or otherwise the same intensity 
of irritation does not lead to as extensive a denudation. And, thirdly, 
by the combined action, it may be, of the irritant and of the hyperemia, 
the fully formed mucous cells are stimulated to produce increased amounts 
of mucin, so that an inflammation of moderate grade is characterized 
by an abundant amount of mucinous discharge rather than of fibrinous 
deposit. 

"We speak of such a moderate case, with exudation of serum con- 
taining abundant mucin, cast-off mucous cells, and relatively few leuko- 
cytes, as a 'catarrhal inflammation;' if there be sufiicient leukocytes ex- 
truded the character is altered to that of a ' mucopurulent inflammation;' if 
more severe, with complete destruction of the mucous membrane proper, 
then, as in serous surfaces, there is the same tendency for the leukocytic 
exudation to favor a deposit of fibrin upon the surface, and then we obtain 
a 'membranous inflammation.' 

"Despite the fact familiar to all that diphtheria is a disease set up by a 
specific bacillus, and the equally well-known fact that a like membranous 
inflammation may be induced by several forms of microbes, we still 
commonly speak of such a membrane as being diphtheritic. It would 
be better to confine this term purely to cases in which we know that the 
Bacillus diphtheria is the causative factor; failing this, we may accept 
the term diphtheritic as covering all such membranous inflammation, 
and employ the term diphtherial for such cases as are of pure diphtherial 
origin. 

"Further, if there be yet more severe destruction of the surface cells, 
this may go on to ulceration. Where we have pyogenic organisms 
present, there is a dissolution and breaking down of any fibrin that is 
formed and consequent absence of a membrane. In such cases there is a 
distinct tendency for the process to extend in the submucosa beneath 
the still intact mucous membrane, the part becoming infiltrated with pus. 
This form is spoken of as 'phlegmonous inflammation.'" 

Chronic Inflammation. — ^The reaction of chronic inflammation con- 
sists of the following phenomena: 

(a) Slightly increased hyperemia. 

(6) Slightly increased cell nutrition. 

(c) Slightly increased migration of leukocytes. 

It is needless to add that the reaction is inadequate to remove the noxa 
or irritant, which, according to pathologists, is usually bacteria of low 
virulence. 

A product of chronic inflammation that is always present is the pro- 
liferation of fixed cells, usually of the least differentiated type, namely, 
connective-tissue cells. 

Having thus briefly defined inflammation, we are prepared to discuss 
its causes. 



108 THE NOSE AND ACCESSORY SINUSES 

The causes of inflammatory diseases of the nose and accessory sinuses 
are divided into two groups, namely: 

1. Excitmg causes. 

2. Predisposing causes. 

1. Exciting Causes. — The exciting causes are bacteria and chemical 
and traumatic destruction of tissue cells. This phase of the subject 
has already been discussed imder Inflammation, and will not be dwelt 
upon in this connection further than to say that pathogenic bacteria 
cannot irritate the tissues of the body so long as the resistance of the cells 
is normal ; that is, so long as they are healthy. There may be an exception 
to this rule when the germs are exceptionally virulent, though this is 
rare. Virulent pathogenic bacteria are constantly present in the upper 
respiratory tract, though they are harmless until the resistance of the 
cells is lowered by some intracorporeal or extraneous influence. 

2. Predisposing Causes. — There are many predisposing causes of 
inflammatory diseases of the nose, some of which are best explained by 
grouping them around a well-recognized physiopathological law, namely, 
When the drainage and ventilation of a mucous membrane-lined cavity is 
impaired or blocked, the conditions are favorable for the growth of patho- 
genic bacteria. 

If this is true, each case of inflammatory disease of the nose and acces- 
sory sinuses should be examined to ascertain if the drainage and ventila- 
tion of these spaces are impaired or blocked. If they are, the obvious 
therapeutic duty is to remove the obstruction by such remedial measures 
as wall best accomplish the purpose. These measures may be either 
medicmal, hygienic, or surgical. 

If, on the contrary, no obstructive lesion is found, other causes for the 
lowered resistance of the tissue should be sought for. If the inflamma- 
tion is a primary acute one, and the lowered resistance is due to shock 
from exposure, it may be useless to attempt to remove the cause, as it 
was transient. The immediate duty in such a case is to promote the 
reaction of inflammation and thus check the inflammatory process. As 
Adami so aptly says, the way to cure inflammation is to increase it. 

In order to logically approach the consideration of the causes of the 
lowered resistance of the mucous membrane of the nose and accessory 
sinuses they should be divided into two groups, namely: 

(a) Extranasal. 

(b) Intranasal. 

Extranasal Predisposing Causes. — Age seems to exert some influ- 
ence upon the resistance of the nasal mucous membrane. Young 
children and young adults are more frequently subject to inflammatory 
diseases of the nose and accessory sinuses than those of more advanced 
years. This is, no doubt, due in part to indiscretion, as the improper 
care and protection of the body from the inclemencies of the weather. 
Persons of more mature years have more mature minds and better 
judgment, and they do not expose themselves needlessly, as in youth 
and childhood. Then, too, the tissues acquire a resistance, or immunity 
to the noxious irritations. 



INFLAMMATION 109 

Sex, perhaps, exerts some influence on the occurrence of inflammatory 
processes. Males are more exposed and more reckless than females, 
hence they are more often affected by inflammatory diseases. They are 
more pugilistic and more often have broken noses and consequent nasal 
obstruction than females. 

Climate undoubtedly influences the occurrence of inflammatory 
processes. In regions where there is much cold, wet weather with sudden 
changes of temperature and of hygroscopic conditions of the atmosphere, 
it is more difficult to protect the body, particularly the feet, from the 
shock incident to such exposures. The shock thus sustained by the 
vasomotor nervous system leads to a lowered resistance of the mucous 
membranes, especially of the nose and accessory sinuses, hence the 
growth of bacteria in these regions is favored. 

Exposure, especially unusual or unequal exposure of the body to damp, 
cold, or other atmospheric and metallurgic conditions, weakens the 
resistance of the tissues. The exposure of the feet to damp and cold is 
a most fruitful source of rhinitis and inflammations elsewhere in the 
body. Draughts striking a single portion of the body are detrimental 
to the resistance of the tissues much more than when the whole body is 
thus exposed. Within certain limitations the exposure of the whole 
body often has a tonic effect, as all the animal mechanisms of the body 
are equally and simultaneously stimulated. When partial exposure is 
experienced, only a portion of the mechanism is stimulated, and an 
unbalance of the functional activities results; that is, there is confusion 
and havoc in the cellular activities, the nasal expression of which is 
often some form of inflammation. 

The clothing is an important factor in maintaining or lowering the 
resistance of the mucous membrane of the upper respiratory tract. Too 
much is as productive of evil as too little clothing. If too much is worn, 
the skin is rendered sensitive to slight exposures, and if too little is worn, 
the body is subjected to continual stress, and exhaustion of the vital 
forces results. Either condition prepares the soil for the growth of 
pathogenic bacteria in the respiratory passages. Perhaps the most 
vulnerable part of the body is the feet, through the soles of which course 
large bloodvessels. Anyway, cold, wet feet is a common cause of acute 
rhinitis and sinuitis. 

The proper selection of underwear is a much mooted question. Wool 
is advocated by some, while linen or linen mesh is strenuously rec- 
ommended by others. In the meantime, most persons buy cotton 
for summer and cotton and wool mixtures for winter wear; not because 
they believe they are the best, but because they are cheaper. My ideas 
on the subject are as follows : 

Linen absorbs moisture better than either cotton or wool, and is, 
therefore, better for sinnmer wear. Wool is warmer than either cotton 
or cotton and wool, and is better for winter wear. Some persons perspire 
easily in winter, and for them linen should be worn next to the skin. If 
this does not retain enough body heat, light wool should be worn over 
the linen underwear. Cotton or cotton and wool mixtures are perhaps 



110 THE XOSE AXD ACCESSORY SINUSES 

never preferable to wool and linen, and wool combinations for the winter 
months. 

The outer garments should be medium weight for the winter months, 
the overgarments being depended upon for extra protection for outdoor 
wear. If the indoor clothing is too heavy, the skin becomes tender and 
subjects the wearer to shock upon undue exposure when out of doors. 
The underclothing and outer garments should, therefore, be selected 
for their absorptive and heat retaining properties. Hard-and-fast rules 
cannot be laid down in reference to the clothing, each subject being a 
law unto himself. The aim should be to so regulate the clothing as to 
avoid either extreme, as to do otherwise subjects the system to shock, 
and thus lowers the cellular resistance and prepares the soil for the growth 
of microorganisms and inflammation. 

The digestive tract is by some writers justly held responsible for in- 
flammatory processes of the upper respiratory tract. If the processes 
of digestion and nutrition are imperfectly performed, noxious material 
enters the vascular lymphatic circulation and thus places extra stress 
upon all the fixed and migrating cells of the body. Lowered resistance, 
therefore, naturally follows. 

Certain constitutioual diseases likewise produce a lowered resistance 
of the tissues, including the mucous membrane of the nose and accessory 
sinuses. Diabetes, syphilis, and all diseases due to faulty metabolism 
especially affect the tissues of the respiratory tract, and predispose them 
to infection and inflammation. 

Heredity probably has no direct influence in the predisposition to 
infectious and inflammatory diseases of the nose. Indirectly it may have 
such an influence. That is, certain anatomical conformations of the 
nasal chambers may be transmitted from parents to the child and thus 
lead to a predisposition to infection and inflammation. 

Adenoids may interfere with the drainage and ventilation of the nose 
and accessory sinuses, or inflammation focalized in them may lower the 
resistance of the mucous membrane of the nasal and accessory sinuses, 
and thus predispose to infection and inflammation. These and other 
extranasal influences may prepare the soil for the growth of pathogenic 
bacteria in the nose and accessory sinuses and may eventuate in em- 
pyema of the sinuses without obstructive lesions in the nose. Wliatever 
the cause of the lowered resistance of the mucous membrane the result 
is the same. 

I do not wish to be understood as saying that infection and inflamma- 
tion always follow a lowered resistance of the nasal mucous membrane. 
I only claim that a lowered resistance predisposes to such a process. The 
virulence of the microorganisms and other conditions enter in the equation. 

Intranasal Predisposing Causes. — In this coimection I wish to repeat 
the physiopathological law which largely explains the occurrence of 
infection and inflammation of the nose and accessory sinuses, namely: 
Cavities lined with 7nucous membrane are predisposed to inflammation 
when their drainage and veniilation are obstructed. 

From experience, we know that when such obstructions are present 



{ 



I NFL AM MA TION 1 1 1 

and are removed, either by local applications or by surgical interference, 
relief often promptly follows. 

Let us direct our attention, therefore, to some of the obstructive 
lesions of the nose which predispose the mucous membrane to infection 
and inflammation. 

Obstruction of the Lower Portion of the Nose. — I desire to first call 
attention to a fact that has long impressed me as very important, namely, 
that obstructions in the lower portion of the nasal cavity have a different 
clinical significance than obstructions located higher in the nasal passages. 
I also wish to call attention to the clinical significance of anterior obstruc- 
tions as contrasted with obstructions otherwise located. 

Obstruction of the Inferior Portion of the Nose. — Obstruction of the 
inferior portion of the nasal passages causes an approximation or an 
impingement of the inferior turbinal against the septum, at least at certain 
points. The pressure may be either intermittent or constant. The 
question of greatest importance is. How does such an obstruction affect 
the drainage and ventilation of the nose and sinuses? As most of the 
mucous membrane of the nose and sinuses is located above the inferior 
turbinal, it is obvious that ventilation is but little affected by such an 
obstruction. The pathway of the inspiratory current is largely limited 
to the middle and superior meatuses of the nose, and, inasmuch as an 
obstruction located inferiorly does not materially occlude the inspiratory 
tract, there is comparatively little disturbance of function. Furthermore, 
the drainage of the secretions is not materially blocked. The usual 
obstructive lesion in this region is a spur or ridge on the septum. The 
ridge is rarely equally prominent along its entire length. On the contrary, 
it presents one or two prominent spines or knuckles which approximate 
or impinge against the inferior turbinated body, thus leaving wide gaps 
through which the secretions may drain to the floor of the nose without 
marked impediment. 

The practical deduction to be drawn from these facts is, that an ob- 
struction in the lower portion of the nose does not markedly reduce 
the resistance of the mucous membrane, especially in the upper portion 
of the nasal chambers and in the accessory sinuses. It does, however, 
have some influence in this direction, and in a degree predisposes to 
infection and inflammation. The crests of the spines or knuckles 
may accumulate secretions, which become desiccated in the form of 
moist or dry crusts. The tissue cells beneath the crusts are injured 
and their resistance lowered, and to this extent there is a predisposition 
to infection and inflammation. Furthermore, the impingement of the 
spur or spine against the outer wall of the nose causes traumatic injury 
and results in some degree of lowered resistance, which may lead to 
bacterial infection and inflammation. The irritation is not usually 
pronounced and only causes an increased hyperemia and nutrition of the 
tissues. 

Obstructive lesions in the lower portion of the nose, therefore, may 
cause a turgescence of the mucous membrane, which is richly supplied 
with erectile tissue (the swell bodies), which after a more or less pro- 



112 THE NOSE AND ACCESSORY SINUSES 

longed period may result in hypertrophy. In the early or tiirgescent 
stage the condition is called turgescent rhinitis; in the later stage it is 
called hypertrophic rhinitis. If, however, repeated infection occurs, the 
irritation is of a different type and causes hyperplastic changes. 

Unfortunately, however, a deviation of the lower portion of the septum 
is usually accompanied by a deviation of the upper portion of the nose in 
the region of the middle turbinal. ^^Qlen this is the case the type of inflam- 
mation is radically different from that present in an uncomplicated lower 
deviation. That is, a deviation in the region of the middle turbinal 
often obstructs the drainage and ventilation of the superior meatus and 
of all, or nearly all, of the nasal accessory sinuses. The secretions are 
retained, undergo decomposition, liberate a ferment, and irritate the 
mucous membrane. In brief, the inflammation is attended by the pro- 
liferation of the least differentiated of the fixed cells, or connective tissue 
cells. In other words hyperplasia of the mucous membrane occurs. 
This is kno^Ti as hyperplastic rhinitis. The irritation from the middle 
turbinal region may extend by continuity of tissue to the inferior turbinal 
and cause hyperplasia of this structure as well. Hence, hyperplastic 
rhinitis often involves both turbmated bodies. In simple deviations, 
however, limited to the lower portion of the nasal chambers the inflamma- 
tion is usually of the hypertrophic type. 

Obstruction of the Anterior Portion of the Nose. — Deviation of the 
anterior portion of the septum from traumatism is the common cause of 
obstruction of the anterior portion of the nasal chamber. The relation- 
ship it bears to inflammatory processes of the nose and accessory sinuses 
is interesting and instructive. An anterior deviation does not interfere 
with the drainage of the secretions except in so far as it may affect the 
mechanical force of the respiratory currents of air. The mechanical 
force of the inspired air is especially manifested in the region of the infun- 
dibulum and posterior ethmoidal cells where the inspiratory current 
sweeps over the hiatus semilunaris and the ostei of the posterior ethmoidal 
cells and causes slight rarefaction of the air within the sinuses drained 
by these openings. The mechanical impact facilitates the flow of 
secretions from the ostei and hiatus semilunaris, and thus prevents 
desiccation and blockage of these openings. To this extent obstructive 
anterior deviations of the septum interfere with drainage. 

The ventilation upon the obstructed side is, however, very materially 
affected. The slight interference with the flow of the secretions caused by 
the absence of the mechanical impact of air results in a moderate reten- 
tion of secretions. Decomposition of the secretions may therefore take 
place and cause a lowered resistance of the mucous membrane, and thus 
establish a predisposition to infection and inflammation. 

When the ridge or spur in the lower portion of the nose extends well 
forward into the vestibule, it also interferes with the ventilation and 
drainage, as described in the preceding paragraph. 

When either type of anterior obstructive deviation is present, another 
and more important etiological factor must be taken into consideration, 
namely, the rarefaction of air posterior to the obstruction. Air being 



INFLAMMATION 113 

unable to enter the nostrils rapidly enough during the descent of the 
diaphragm is rarefied, or a state of negative air pressure is established. 
This, according to Bier's theory, should prevent serious inflammatory 
processes, as the negative air pressure thus produced promotes the reac- 
tion of inflammation and should prevent serious inflammatory disease. 
Doubtless the negative pressure thus automatically produced does exert 
a favorable influence upon the inflammatory process excited by the lack 
of ventilation and the slight retention of the secretions. Thus, strange 
as it may seem, the anterior obstructive lesion predisposes to infection 
and inflammation, and at the same time tends to cure it. 

Clinically, I have often noted the comparatively slight inflammatory 
disease of the nasal mucous membrane present in simple anterior devia- 
tions. 

The chief departure from the normal is a turgescent or a hypertrophic 
rhinitis of the inferior turbinals. Little pathological change is present in 
the middle turbinal region unless there is an associated obstruction in 
that location. The negative air pressure easily accounts for the turges- 
cence of the erectile tissue of the inferior turbinals. After a prolonged 
duration of the turgescence, whether intermittent, alternating, or con- 
stant, hypertrophy occurs as a result of the increased nutrition. 

Obstruction in the Middle Turbinal Region. — Obstruction in this por- 
tion of the nasal chambers is productive of more serious inflammatory 
disease of the nose and accessory sinuses than obstruction in any other 
portion of the nose. The reason is obvious when we recall the fact that 
the ostei and sphenoidal sinuses drain into the superior meatus above the 
middle turbmal, while the frontal, anterior ethmoidal, and antral sinuses 
drain mto the middle meatus beneath the middle turbinal. 

If the septum is deviated so as to press against or approximate near 
to the middle turbinal, the olfactory fissure is blocked and the drainage 
of the posterior ethmoidal, and possibly of the sphenoidal cells, is inter- 
fered with. 

Clinically I have noted the presence of two types of deviations of the 
septum that close, or nearly close, the olfactory fissure. One is a bowing 
of the perpendicular plate of the ethmoid bone and triangular cartilage, 
and the other is a thickening of the septum in the region of the middle 
turbinated body. The bowed septum is thin and easily corrected by the 
submucous resection of the septum, whereas the thickened septum often 
involves only the mucous membrane and is more difficult to correct. 

In some subjects there are large pneumatic spaces in the middle 
turbinal which may either close a part or all of the olfactory fissure, or 
they may encroach upon the hiatus semilunaris beneath it. In the first 
instance the drainage and ventilation of the superior meatus of the nose, 
and in the second instance the drainage and ventilation of the frontal, 
anterior ethmoidal, and maxillary sinuses are impaired. 

A large bulla ethmoidal is projecting median ward and downward may 
obstruct the hiatus semilunaris, and thus obstruct the drainage and 
ventilation of the cells draining into the infundibulum, namely, the frontal, 
anterior ethmoidal, and maxillary sinuses. 



114 THE NOSE AND ACCESSORY SINUSES 

Likewise, the occasional pressure of cells in the inner wall of the 
infundibulum, or uncinate process of the ethmoidal bone, may block 
the infundibulum and cause serious inflammatory disease of the frontal 
and anterior ethmoidal cells and the maxillary antrum ("vicious circle"). 

In about 50 per cent, of the cases the frontonasal canal does not com- 
municate with the mfundibuhun, but opens directly into the middle meatus 
more anteriorly. In these subjects an enlarged projecting bulla eth- 
moidalis and cells in the uncinate process would not block the drainage 
and ventilation of the cells draining through the frontonasal canal, namely, 
the frontal and anterior ethmoidal cells. The ostium of the antrum, 
however, may be obstructed as it always opens into the infundibulum. 

The Results of High Obstructions in the Nose. — When the olfac- 
tory fissure is obstructed by either septal or turbinal deformity, the 
drainage of the secretions and the ventilation of the posterior ethmoidal 
and sphenoidal sinuses are impaired. The secretions are retained and 
undergo retrograde changes. The mucous membrane bathed in the 
secretions is injured and its functional activity and resistance are 
lowered. The biochemical substances liberated in the process of 
decomposition constantly irritate the mucous membrane, especially 
of the middle turbinated body. Acute infection occasionally occurs. 
During the intervals between the acute inflammatory processes a mild 
staphylococcal or other mfectious inflammation persists. Under these 
conditions there is a proliferation of fixed cells in the tissues, usually 
the least dift'erentiated of the fixed cells, viz., connective-tissue cells. 

The result is knowTi as hyperplastic rhinitis, which chiefly involves 
the middle turbinated body, though it often extends to the inferior tur- 
binal as well. 

Obstriiction of the Olfactory Fissure. — The partial or complete closure 
of the olfactory fissure and the consequent retention of the secretions 
of the superior meatus, and the ethmoidal and sphenoidal sinuses drain- 
ing into it, cause hyperplastic changes in the mucous membrane, not alone 
of the middle turbinal, but of the superior meatus and of the ethmoidal 
and sphenoidal sinuses opening into it. The conditions thus produced 
are favorable for infection and inflammation. The inflammatory process 
may be either catarrhal, purulent, fibrinous, or phlegmonous in type, 
and in each instance it is in part due to pathogenic microorganisms. 

The sinuitis thus excited may contmue for years without engaging 
the attention of either the patient or physician. Headache and slight 
dizziness, aggravated upon stooping, may be the only symptoms com- 
plained of, except, possibly, recurrent attacks of acute coryza. Or the 
sinuitis may be distinctly and frankly purulent, with copious discharge 
into the epiphar^Tix, and possibly to some extent through the olfactory 
fissure into the middle meatus. 

Atrophic rhinitis with ozena is, in my opinion, in adults often a sup- 
purative sinuitis with atrophy of the mucous membrane. Space does 
not permit of a full discussion of this phase of the subject. Personally 
I have repeatedly overcome the ozenic secretion by treating the case 
as though it were a suppurative sinuitis. I have made skiagraphs of 



INFLAMMATION 115 

several cases of atrophic rhinitis with ozena, and without exception they 
have shown the existence of sinus disease. This does not, of course, 
determine which was primary, the atrophic rhinitis or the sinuitis. My 
opinion is largely based upon the results following the treatment for the 
sinuitis. 

Obstruction Due to the Bulla Ethmoidalis in the Middle Turbinal and 
Uncinate Cells. — As previously stated, a large bulla ethmoidalis may 
occlude the infundibulum and thus block the drainage and ventilation 
of the maxillary sinus, the frontal and anterior ethmoidal cells. This, 
as heretofore explained, causes the retention of the secretions and 
lowered resistance of the tissue, thus establishing a predisposition to 
infection and inflammation. (See "Vicious Circle" of the Nose.) 

Cells in the middle turbinated body and uncinate process hkewise 
may block the infundibulum and cause similar results. The exception 
has been referred to wherein the frontonasal canal opens directly into the 
middle meatus anterior to the infundibulum. 

It appears, therefore, that there are several factors entering into the 
causation of inflammatory diseases of the nose and accessory sinuses. 
The excitmg cause is nearly always pathogenic microorganisms, while 
the predisposing causes are numerous extranasal influences which are 
often combmed with obstructive lesions in the nose. The latter should 
always be studied with reference to whether they interfere with the 
drainage and ventilation of the nose and accessory sinuses. If only extra- 
nasal causes of lowered resistance are found, the treatment should be 
addressed to their removal; and if in addition to the extranasal influences 
obstructive lesions are found, they should be corrected by probing or by 
surgical interference. 

Conclusions.- — 1. Acute inflammation is usually a threefold reaction 
excited by pathogenic bacteria and their toxins, namely : 
(a) Increased passive hyperemia. 
(6) Increased nutrition of the tissues. 
(c) Increased migration of leukocytes. 

The reaction of acute inflammation is the response of Nature's forces 
for the purpose of destroying the bacteria and their toxins. 

2. The reaction of inflammation is usually inadequate to quickly 
remove the infective bacteria and their toxins, hence the inflammation 
contmues for several days, or it may be indefinitely prolonged. 

3. Chronic inflammation consists of the same reactions in much less 
degree, and is still further characterized by the proliferation of fixed 
cells into the tissues, notably connective-tissue cells. 

4. The exciting cause of inflammation is generally some pathogenic 
microorganism. 

5. Pathogenic bacteria do not, per se, cause inflammation. There 
must be a lowered resistance of the tissues before they will rapidly mul- 
tiply and produce inflammation. 

6. Anything that lowers the vitality or resistance of the mucous mem- 
brane of the nose and accessory sinuses predisposes it to infection and 
inflammation. 



116 THE XOSE AXD ACCESSORY SIXUSES 

7. The extranasal influences that lower the vitahty of the mucous 
membrane are sex, climate, exposure, improper clothing, digestive 
disorders, constitutional diseases and dyscrasias, hereditary anatomical 
peculiarities of the framework of the nose, adenoids, etc. 

S. The intranasal predisposing causes of inflammation of the mucous 
membrane of the nose and accessory sinuses are, perhaps, best explained 
by the well-recognized law: Obstruction of the drainage and ventilation 
of mucous-lined cavities predisposes them to infection and inflammation. 
The character of the inflammation and the end result are partially 
determined by the location of the obstruction in reference to the various 
tissues of the nose and to the accessory sinuses. 

9. Anterior and inferior obstructions more often cause turgescent 
and h^-pertrophic rhinitis, as they do not materially interfere with the 
tlrainage of the secretions, and therefore cause very little or no irritation. 

10. Obstruction higher in the nose, in the region of the middle turbinal 
and the infundibulum, causes the retention of the secretions and interferes 
with the ventilation of the superior meatus and the accessory sinuses, thus 
lowering the resistance of the tissues and establishing a marked predis- 
position to infection and inflammation of the nasal and accessory sinuses. 
The inflammation may be catarrhal or suppurative, and acute or chronic 
in type. 

11. The long-continued mild irritation excited by obstructive lesions 
in the middle turbinal region often results in hyperplastic rhinitis, which 
may be limited to the middle turbinal, though it may extend to the 
inferior turbinal. 

12. Inflammation also extends to adjacent parts by the continuity of 
tissue, hence it may extend from one part of the nasal mucous mem- 
brane to another, or it may extend from the nasal mucous membrane to 
the sinuses, the Eustachian tube and cavum tympani. 



I 



CHAPTEE VII. 

THE PRINCIPLES OF TREATMENT OF INFLAMMATIONS. THE 

MODALITIES FOR PROMOTING THE REACTIONS 

OF INFLAMMATION. 

Acute Inflammation. — As Adami so aptly says," Inflammation is a 
danger signal, but by no means necessarily a danger." Inflammation 
is a beneficent reaction, Nature's attempt to ward off or destroy an 
invading irritant. The inflammatory process thus started should be 
encouraged rather than discouraged, at least for a short time. The 
increased hyperemia and leukocytosis should be added to rather than 
detracted from. Cold applications are generally contraindicated, as they 
diminish the hyperemia and leukocytosis and lower the cell resistance. 

Heat is indicated, as it increases the cellular resistance and leuko- 
cytosis, at least up to a certain pomt. Passive hyperemia by Bier's method 
of treatment is along the right line. The hot-air treatment and the leuko- 
descent light also increase the hyperemia and leukocytosis, hence the 
irritant causing the inflammation is disposed of, the inflammation sub- 
sides, and normal conditions are restored. 

Wliatever the mode of treatment, its object should be to augment the 
hyperemia and leukocytosis. As Adami says, the inflammation is not 
the real danger, but is the signal of danger, and as such its warning should 
he heeded. 

Physiological and physical rest for the inflamed part should be pre- 
scribed. If the middle ear is infected, quiet should be enjoined. If 
the eye, a darkened room. In addition to physiological rest, local 
hyperemia and leukocytosis should be augmented by the use of the 
leukodescent light. Bier's treatment, etc., to hasten the destruction of the 
infecting bacteria. If cold applications are used, the local hyperemia 
and leukocytosis are reduced, the cell resistance is lowered, and Nature's 
effort to throw off the irritant is thwarted. Remember that inflammation 
is not a destructive process, but is a benign process for the purpose of 
destroying the microorganisms and their toxins. 

Promotion of the Reaction of Inflammation. — The grand purpose 
of treatment should be to promote the inflammatory reaction. Failing 
in this, or if, for various reasons to be discussed later, it is not deemed 
wise to wait the full establishment of the reaction of inflammation, opera- 
tive interference may be called for. Adami classifies reactions of inflam- 
mation as follows : 
(a) Adequate. 

(6) Inadequate to neutralize the irritant and bring about repair. 
(c) Excessive for these purposes. 



118 THE NOSE AND ACCESSORY SINUSES 

(a) Adequate reaction is present in aseptic incised wounds, the natural 
liealing of fractures, etc. Such conditions need no local treatment, as 
the reaction of the tissue cells is adequate to dispose of the irritant noxa; 
that is, the passive hyperemia and leukocytosis is sufficient to destroy 
the bacteria, toxins, and broken-down cells. At the end of about twenty- 
four hours the reaction has reached its maximum. The cell resistance 
and the nature of the lesion are favorable for the establishment of adequate 
reaction; hence, interference, other than to maintain these conditions, 
is contraindicated. Healthy blood and a normal nervous system are 
prime requisites for establishing adequate reaction. Physiological rest of 
the injured parts and the regulation of the excretory organs are the only 
indications for treatment in such cases. 

If the infection is virulent, or the condition of the blood and the excre- 
tory organs are below normal, the beneficent reactions of inflammation 
will be inadequate to speedily remove the infectious irritant, at least 
before impairment of the tissues has occurred. Thus in mild but pro- 
longed middle-ear inflammation the repair is usually so slow that, 
unaided by the aurist, the integrity of the conduction apparatus may be 
impaired and permanent deafness follow. In such a case there is 
inadequate reaction, hence the reaction of inflammation should be pro- 
moted. 

ib) Inadequate reaction is usually present in most cases of acute 
inflammation. Formerly most surgeons regarded the reaction as 
excessive and attempted to reduce it. Such a course is inimical to the 
wefl-being of the patient. The reaction needs promotion rather than 
abatement. It should be remembered that the increased temperature, 
pulse, and respiration are not essential parts of the reaction; they are 
incidental concomitant phenomena. The reaction, that is, the aroused 
forces of Nature to combat the invading microorganisms, the passive 
hyperemia and the leukocytosis being inadequate to dispose of the noxa 
or irritant, should be promoted, not abated. 

Many methods of increasing the hyperemia and leukocytic migra- 
tion are in vogue. Among them are poultices, counterirritation, 
scarification, constriction by ligature, negative air pressure, massage, 
leukodescent light, heat, incisions, and irrigations with bland irritants, as 
normal salt solutions. 

Some of the modes of treatment have been in use for many centuries, 
perhaps all of them in some modified form, at least in isolated instances. 
1 )r. Brawley called my attention to the fact that certain American Indians 
cured acute coryza by constricting the neck of the patient with the hands, 
thus practising what Bier has reduced to scientific principles. Rhinol- 
ogists have long resorted to irrigation of the accessory sinuses of the nose 
in the treatment of sinuitis. They have also used more irritating 
solutions. Irrigations with normal salt solution have been used with the 
idea of removing the products of inflammation, rather than increasing 
the hyperemia and the leukocytic migration. Perhaps an increased 
familiarity widi the principles underlying the treatment of inflammation 
will materially modify the technique employed in the treatment of in- 



THE PRINCIPLES OF TREATMENT OF INFLAMMATIONS HO 

flammatory diseases of the upper respiratory tract. Each case should 
be studied individually and the modality applied that best meets the 
peculiar conditions present. 

In acute inflammation of the maxillary sinus the surgeon should 
decide whether he will resort to counterirritation, irrigation, the leuco- 
descent light, negative air pressure, or some surgical procedure. The 
chief question is, What method of treatment will best promote hyperemia 
and the migration of leukocytes ? The aim should not be to check the 
inflammatory process in the sinus, as that is established to rid the parts 
of the irritant noxa (pathogenic microorganisms) and to prevent its 
extension to contiguous structures. A counterirritant is not desirable, 
as it may temporarily, and possibly permanently, disfigure the face. 
Irrigation is usually impossible, except through an artificial puncture. 
The leukodescent light is easily applied, relieves pain, and increases the 
migration of leukocytes to the infected area. The expense of the apparatus 
practically limits its use to office and hospital practice. Its use is also 
limited to districts supplied with electric power. Where it is practicable 
to use it, it is a valuable mode of treatment. Bier's constriction treat- 
ment necessitates the application of an elastic band around the neck, and 
is more or less uncomfortable. It is, nevertheless, easily applied, and 
may be used by any physician understanding its application. Nega- 
tive air pressure may be used in the nasal chambers by bulb suction, 
hence its application is not limited by expense or complex apparatus. 
Each treatment should extend over a period of several minutes, hence 
the bulb apparatus necessitates prolonged personal attention and mus- 
cular effort on the part of the patient or an attendant. Other and 
better negative air-pressure apparatuses require water, compressed air, 
or electric motor power, and are, therefore, practically limited to ofiice 
and hospital practice. The mode of treatment is of considerable thera- 
peutic value in acute sinus inflammation, and should be utilized much 
more than it is. Puncture through the inferior meatus increases the 
hyperemia and leukocytic migration, but it soon closes and necessitates 
a repetition of the procedure. It is a disagreeable procedure, and is some- 
times complicated by a deeper infection of the tissues, marked soreness 
being present. It appears from the foregoing cursory review of some 
of the methods of procedure that the leukodescent light and the negative 
air pressure offer the most rational and effective modes of promoting 
adequate reaction in acute sinuitis. None are of universal application, 
for the reasons already given, hence, the surgeon may be compelled to 
resort to puncture, or puncture and irrigation combined, or to some 
other method of procedure. 

This discussion is given not because it is intended as a guide in the 
treatment of sinus inflammation, but to show that various factors have 
to be considered in each case. 

In acute otitis media the various modalities must be considered in 
connection with the peculiar anatomical and physiological conditions 
present. The location of the middle ear in a deep bony recess is an 
obstacle to the application of the leukodescent light. Heat is easily applied 



120 THE NOSE AND ACCESSORY SINUSES 

by means of a hot-air apparatus or by hot irrigations through the external 
meatus. Counterirritation over the mastoid is but feebly effective. 
Cold is ordinarily contraindicated, as it diminishes the congestion and 
leukocytic migration. An exception in its favor is in inflammation of 
an encapsulated organ. The organ of hearing, being encased in bony 
tissue, is essentially an encapsulated organ, its capacity for expansion 
under congestion being limited. Only its outer wall, the membrana 
tym])ani, allows of expansion. Cold should be considered as a therapeutic 
measure imder certain conditions. The congestive reaction following 
the ischemia produced by the cold may be beneficial. Another factor of 
great importance is die })resence of the delicate chain of bones concerned 
in the transmission of sound waves to the labyrinth. If the inflamma- 
tion, widi its attending inflammatory products, continues for any con- 
siderable length of time, the inflammatory exudates become organized 
and the hearing is impaired. It is important, therefore, to institute some 
therapeutic measure that will quickly check the infectious process. Two 
alternatives suggest themselves, namely, incision of the drumhead and the 
local application of an irritant drug to the ear drum. A 12 per cent, 
solution of carbolic acid in glycerin has proved of decided value for this 
purpose (A. H. Andrews). 

In acute laryngitis the following considerations are presented. Counter- 
irritation is inadequate to sufRciendy promote the inflammatory reaction. 
Scarification and incision are impracticable. The leukodescent light 
is probably not active enough, unless it is applied three or four times a 
day. The patient should l3e confined to the house, hence the light is 
practically out of the question unless a lamp is installed. The inhala- 
tion of hot medicated vapors promotes hyperemia and leukocytosis, but 
not sufficiently to be of great value except as an adjunct to other modes 
of treatment. The marked muscular activity of the soft parts of the 
lar}Tix is a great impediment to the successful treatment of larjTigitis. 
The prime object of treatment should, therefore, be to abolish the func- 
tional activity of the intrinsic muscles of the larjaix. This can be done 
by ])roliibiting the use of the voice, requiring all conversation to be 
carried on with pencil and paper. Twenty-four hours of such functional 
rest often results in the triumph of the reactive inflammatory process over 
the invading bacteria and their toxins. Vibratory massage applied 
externally over the lar}aix increases the congestion, unloads the lymphatic 
vessels, and promotes leukocytic migration. 

The foregoing illustrative cases suggest the method of thought to be 
applied in the selection of the modalities for the promotion of the reactions 
of inflammation in the treatment of acute inflammation, where inade- 
quate reaction is the rule. 

(c) Excessive reaction is rarely present. ^Nhen present it is usually 
due to an excessively virulent microorganism, or to marasmus or other 
cause of lowered vitality. In such conditions a moderately virulent 
microorganism may cause excessive reaction. The tissues are intensely 
swollen, and a linear incision quickly promotes normal reaction by 
converting the passive into active congestion and unloading die engorged 



THE PRINCIPLES OF TREATMENT OF INFLAMMATIONS 121 

lymphatics. With these changes normal or adequate reaction is es- 
tablished. 

It is in these cases that the application of cold is indicated. Cold 
reduces the hyperemia, checks leukocytic migration, and diminishes the 
excessive cell proliferation. 

General Systemic Treatment. — The objects of all systemic treatment 
for the promotion of normal reactive processes are (a) to increase the 
resistance of the cell structures, and (6) to eliminate the infecting micro- 
organisms. To accomplish these ends the food should be highly nutri- 
tious but bland in character, while the elimination of the toxic products 
should be encouraged by the administration of saline cathartics. The 
skin, liver, and kidneys should also be rendered more active. 

Excessive febrile reaction should be overcome by hydrotherapy or 
the administration of quinine, salicylates, etc. 

Pain may be relieved by the administration of opiates or belladona, 
though the leukodescent light is a better remedy. 

Treatment of Chronic Inflammation. — Adami says: "It is through 
no desire to be epigrammatic that one makes the statement that there is no 
treatment for chronic inflammation. The process consists, as we have 
seen, of hyperemia, slight exudation, slightly increased leukocytosis, and 
great tissue proliferation. 

"The last-named process is probably not to be checked by any direct 
means we can employ; and any mechanical or chemical means we use 
is likely, per se, to increase rather than diminish it. But our mechanical 
means, directed toward an increase of the rapidity of income and output 
of the tissues, do more good in this way than harm in the other way. 
It may thus be said that our treatment of a case of chronic inflammation 
is not applied so much to the condition as in spite of it. If fibrosis has 
taken place, we cannot wholly undo it; but by increasing the vitality of 
the tissues we may check the continuance of the process and may render 
the absorption of the debris more rapid. 

"Newly formed fibrous tissue may, however, in some cases undergo 
absorption. The remarkable diminution in size of syphilitic gumma ta 
under potassium iodide can mean nothing else; as, also, fibroid tubercles 
scattered over the peritoneum seen at one laparotomy have been found 
wholly absent at a subsequent laparotomy some months later. This 
fact affords the suggestion that a mild grade of acute inflammation 
superimposed upon a chronic favors absorption and explains the good 
effects of induced hyperemia in leading to the removal of adhesions and 
the restoration of movements in joints. 

"If a low degree of microbic inflammation be still present there is 
an accompanying hyperemia, with slowing of the blood stream; the nutri- 
tion of the part, while appearing to be excessive, is often under par, 
and by the use of various agents we strive to increase its nutrition. Such 
modes of treatment are as follows: The use of cold for sliort times at 
intervals, bringing about an alternation of contraction and dilatation of 
the bloodvessels; the use of heat more or less continually; the use of 
electricity; rubbing, handling, and massage of the tissues, to the end that 



122 THE NOSE AND ACCESSORY SINUSES 

the venous exodus from the part may be more rapid and more thorough; 
active and passive movement of the part, to accompKsh the same result 
by pressure of contracting muscles; the use of counterirritation, rube- 
facients, vesicants, etc., which have this in common, that they probably 
increase the total amount of blood brought to the part. The use of the 
seton, now discontinued, had in view the same end. 

"The result of all these modes of treatment is that the overturn of 
blood is rendered much greater, the venous return assisted, and the 
arterial blood permitted to enter more freely. The normal diapedesis 
of leukocytes tends to the removal of cellular debris, and the circulation 
in the part is approximated to the normal." 

In the early stages of adhesive processes of the middle ear the appli- 
cation of the foregoing principles of treatment may accomplish much 
toward their removal. The internal administration of theosinonin has 
proved beneficial in such cases. Its use in old fibrosis of the middle 
ear is without appreciable effect. It is probable that any beneficial 
effects of pneumomassage is due more to the increased lymphatic flow, 
the increased nutrition, and to the absorption of the inflammatory pro- 
ducts than to the increased mobility given to the ossicles. 

In hyperplastic rhinitis the object of treatment should be to remove 
the cause of the irritation, usually a chronic sinus inflammation with its 
discharge. Operative interference is usually necessary. In addition 
to the removal of the primary source of irritation, a reactive acute in- 
flammation is superimposed upon the chronic inflammation. This 
favors the absorption of the products of chronic inflammation. 



MODALITIES FOR PROMOTING THE REACTION OF 
INFLAMMATION. 

In the first part of this chapter I have shown that acute inflammation 
is a series of reactions excited by the presence of bacteria, their toxins, 
and the cellular debris. The object of the reactions is to rid the tissues 
of the bacteria, toxins, and cellular debris. Experience has shown that 
in acute inflammation the reaction is not sufficient to do this as quickly 
as should be to prevent damage to the tissues. That is, necrosis, cellular 
deposits, and adhesive processes are liable to occur before the reaction 
frees the cellular structures of the irritants. It is rational therapy, 
therefore, to promote the inflammatory reaction rather than to repress 
it. As a concrete example, I will cite acute coryza, or "cold in the head." 
This is a reaction due to certain bacteria and their toxins. It is under- 
stood, of course, that certain predisposing causes have prepared the soil 
for the growth of the bacteria. Ordinarily, the reaction (increased 
hyperemia and leukocytosis) is inadequate to quickly throw off the 
bacteria and the toxin. The question naturally arises, how to promote 
or increase the reaction ? Do not make the common mistake of assuming 
that the inflammatory reaction is already excessive. It may be, but it 
is usually inadequate. Those who assume the reaction to be excessive 



MODALITIES FOR THE REACTION OF INFLAMMATION 123 

often apply adrenalin locally to reduce the reaction. This reduces the 
hyperemia, cell nutrition, and leukocytosis, whereas, they should be 
increased. It does establish better drainage. 

The same law applies to nearly all acute inflammations of the upper 
respiratory tract, including the ear. It is the purpose of this section to 
discuss the various procedures whereby the reaction of inflammation is 
promoted or increased, and to outline the indications and the methods 
for their therapeutic application. 

Counterirritation. — Counterirritation has long been used to counter- 
act inflammatory processes, the prevalent idea being that it diverted the 
blood to the surface and away from the seat of inflammation. We 
know now that while its use was rational, the explanation of its good 
effects was irrational. Counterirritation applied over the inflamed 
area not only increases the superficial hyperemia, but it increases it in 
the deeper tissues as well. It also increases the leukocytosis and cell 
nutrition. Thus, instead of counteracting the inflammation, it promotes 
the inflammatory reaction. 

Counterirritation has but little place in otolaryngological practice, for 
two reasons: (1) Because the blistering and scarring which occasionally 
result from it are objectionable for cosmetic reasons, and should surgical 
interference become necessary the skin is in bad condition; (2) because 
there are other modalities that are more efficacious. 

Poulticing. — This is also an old method of treating inflammation. 
The moist pabulum of bread and milk, or other ingredients, is usually 
applied hot, the whole being covered with cloths or oiled silk to retain 
the heat and moisture. While poulticing promotes inflammatory 
reaction, it has fallen into disuse, because better modalities have taken 
its place. It obviously has little place about the head. 

Scarification and Wet Cupping; Artificial Leeching.— Scarifiers 
were once in every family physician's outfit, whereas they are now 
rarely seen. Scarification was usually combined with cupping, and 
was designated "wet cupping." With a comb-like knife or with 
a series of concealed blades liberated by pressing a spring, the super- 
ficial layers of the skin were many times incised, and a cup in which 
a few drops of alcohol or a piece of paper was burned was quickly 
applied over the incised surface, and the negative air pressure created by 
the heat in the cup caused free oozing of blood. The idea prevailed 
that this diminished the excessive inflammatory reaction, whereas, as a 
matter of fact, it increased it. That is, it increased the hyperemia 
and leukocytosis, established adequate reaction, and hastened the elim- 
ination of the bacteria, toxins, and cellular detritus. 

Wet cupping was formerly much practised in acute mastoiditis, and 
doubtless with beneficial results. I have often used it for this purpose, 
and recommend it as a valuable mode of treatment in the early stages. 

Leeching. — This is a venerable tlierapeutic measure of great value in 
promoting inflammatory reaction. I have seen children with broncho- 
pneumonia quickly pass from a state of stupefaction, with a pulse of 
200 per minute, to one of complete consciousness, with quiet respirations 



124 THE XOSE AND ACCESSORY SIXUSES 

and a pulse of 100 per minute after the application of a few leeches to 
the chest. Likewise, I have seen the pain and tenderness in acute 
mastoiditis subside under leeching. With the improved technique of 
mastoid surgery-, and with the accmnulated observations of aural sur- 
geons to the effect that, Avhile many of the cases of acute mastoiditis 
subsided, but few were cured, leeching and kindred measures have 
been gradually abandoned. The kepiote to the present-day mastoid 
therapy is the total eradication of the diseased process at the earliest 
possible moment by surgical intervention. Doubtless the pendulum 
has swung too far to the surgical side. An increased knowledge of the 
pathology of inflammation and of the processes of repair will enable 
the surgeon to difl'erentiate more closely between the operative and non- 
operative cases. 

From three to six leeches may be applied over the mastoid process and 
in front of the tragus in the veiy early stages of acute mastoiditis with 
decidedly beneficial effect. This is good treatment while watching the 
development of a case, and in some cases promotes the inflammatory 
reaction (increased hyperemia and leukocytosis) to such a degree as to 
lead to a speedy recovery. It is doubtful if leeching is efficacious after 
the disease has continued several days. Even then, however, it will 
affect the inflammatory process favorably, though not enough to effect 
a cure. The case must then be treated surgically (removal of adenoids 
in children, and possibly the exenteration of the ethmoidal sinuses in 
adults, or a mastoid operation) or allowed to assume a latent or chronic 
form. 

Irrigation or Lavage. — This mode of treatment has long been applied 
to inflamed mucous-lined cavities of the nose and accessory sinuses 
of the nose. The prevalent idea as to its mode of action is that the solu- 
tion used mechanically removes the inflammatory secretions, and thus 
lessens the noxa or local irritant, all of which is doubtless true. It also 
increases the local hyperemia and migration of leukocytes, i. e., promotes 
the inflammatory reaction. Its action, however, is usually slight and 
transient, and inadequate for the purpose. The inflammatory process 
passes into the chronic type with tissue deposit, thus causing permanent 
changes detrimental to the physiological integrity of the structures. There 
are circumstances, however, under which lavage must be used in the 
treatment of sinuitis. If, for any reason, operation is refused or is not 
advisable, lavage may be practised through the ostia or through artificial 
openings into the sinuses. In acute cases the reaction thus established 
quickly overcomes the noxa, and healing speedily results. In chronic 
cases the reaction thus promoted is inadequate, and, indeed, in the nature 
of things, is not calculated to arrest the noxious process. Chronic 
inflammation consists of hyperemia, slight exudation, slight migration 
of leukocytes, and great tissue proliferation. The last-named process is 
probably not to be checked by any direct means we can employ. 

From the foregoing it is plainly good treatment to employ such solu- 
tions by irrigation as will increase the hyperemia, the migration of leuko- 
cytes, and tlic nutrition of tlie chronicallv inflamed mucous membrane. 



MODALITIES FOR THE REACTION OF INFLAMMATION 125 

To these ends normal salt, boric acid, mild iodine, and other solutions 
may be employed. Even normal salt solution promotes the reaction 
of inflammation. It is to be expected, therefore, that while lavage 
will not remove the tissue proliferation, it will promote the inflamma- 
tory reaction, increase the nutrition, and remove the infective noxa still 
remaining. It also removes the irritating toxic secretions and thus 
relieves the tissues of another source of vicious irritation. 

Massage. — Under this term are mcluded three modalities of treat- 
ment, namely: (a) Manual massage, (6) mechanical massage, and (c) 
alternate rarefaction and condensation of air in a cavity, the so-called 
pneumomassage as devised by Delstanche and as modified in the various 
mechanically driven machines so commonly used in America. 

The effect of massage upon inflamed tissue is to increase the hyperemia 
and nutrition, and the diapedesis of leukocytes. The inflammatory 
reaction is thereby promoted and the tissues measurably relieved of the 
irritant noxa. 

(a) Massage of the larynx in acute laryngitis and for the relief of 
singers' nodules has been used with decided benefit. It may be applied 
by hand manipulations or by a vibratory massage machine. The motion 
and physical force thus applied to the exterior of the larynx increases the 
hyperemia and leukocytosis of the parts, and thus aids in the removal 
of bacterial infection and improves the nutrition of the cells, thereby 
fostering resistance to mechanical irritation from faulty use of the vocal 
apparatus. 

(6) Mechanical or vibratory massage is of special value in acute 
adenitis of the cervical glands, its application quickly reducing the 
swelling and tenderness. It is not good treatment, however, to limit 
the attention to this mode of procedure, for to do so is to ignore the 
primary source of the glandular disease, namely, the tonsils, adenoids, and 
pharyngeal glands. The massage is only an adjunct to the treatment. 

(c) Pneumomassage by means of hand or mechanically driven devices 
has been used extensively and almost empirically for the relief of deaf- 
ness and tinnitus, with but little result. The same procedure applied 
in cases of acute otitis media would be of vastly more use to patients. 
That it has been used for this purpose I am unprepared to say. It 
stands to reason, however, that the movements thus imparted to the 
membrana tympani and the ossicular chain would increase the hyperemia, 
the cell nutrition, and the migration of the leukocytes in the inflamed 
mucous membrane, and thus hasten the reparative process. 

Leukodescent Light. — During the past few years radiant energy in 
the form of h'ght from a 500 candle-power incandescent globe has been 
used in the treatment of inflammatory processes. The beneficial effects 
are, perhaps, best explained by saying that it promotes inflammatory 
reaction (by hyperemia, cell nutrition, and diapedesis of leukocytes) 
and thus hastens the removal of the bacteria and other noxious material 
causing the irritation. I have been using the light for about three years, 
and have found it one of the most useful, if not the most useful, mechani- 
cal agency for promoting reaction in inflammatory diseases of the upper 



126 THE NOSE AND ACCESSORY SINUSES 

respiratory tract. Acute coryza sometimes succumbs under its influence. 
I have repeatedly seen chronic suppurative sinuitis become painless and 
cease to discharge purulent secretions into the nose. I have never cured 
such a case with it, the purulent discharge returning in a few days or 
weeks after ceasing its use. ^Vllether its prolonged use would have 
effected a cure I am not prepared to state. The light relieves pain, 
tenderness, and swelling in a surprisingly short time, and superficial 
infections sometimes disappear rapidly. This is not surprising in view of 
our knowledge of radiant energy from the Finsen light, the Rontgen 
ray, and the high-frequency electrical currents. The 500 candle-power 
lamp is known to possess high chemical and penetrating properties. In 
addition to this the heat rays are, of themselves, of great usefulness in 
promoting inflammatory reactions. The combination of the chemical 
and the heat rays is ideal for the treatment of inflammatory diseases, as 
the reaction excited is more profound than with either the heat or the 
chemical rays alone. The range of application of the 500 candle-power 
lamp is as wide as inflammation itself. It wiU not cure all cases, but if 
the reaction is inadequate it will benefit in so far as it promotes ade- 
quate reaction. If there is excessive reaction its use is contraindicated, 
cold being indicated. If adequate reaction is present, as in incised 
wounds healing by first intention, its use is contraindicated. It should 
be remembered that the inflammatory reaction usually reaches its 
maximum of efficiency at the end of about twenty-four hours, and that 
to get the maximum results by any of the modalities referred to in 
this section they should be applied within the first twenty-four hours, 
before tissue proliferation begins. Tissue proliferation of a permanent 
type begins at about the fifth day of acute inflammation, and becomes 
more and more established as time goes on. This is practically illus- 
trated in acute mastoiditis, where the simple operation is almost always 
successful if performed within the first five days of the disease, whereas 
after that period its permanent success is more and more doubtful. 

The explanation is obvious in view of the well-known fact that tissue 
proliferation is a manifestation of chronic inflammation, and that chronic 
inflammation is not readily checked by any direct mechanical means at 
our command, except by a most thorough exenteration of all the diseased 
tissue and the establishment of free drainage. 

Bier's Treatment. — Bier's treatment has attracted a great deal of 
attention within the last few years. It is based upon the promotion of 
hyperemia in the treatment of acute suppurative, tuberculous, and other 
conditions. He promotes both active and passive hyperemia; active 
by the use of hot air, and passive by constriction of the parts and by 
negative air pressure in cavities. He finds active hyperemia of more 
value in chronic cases, where proliferated tissue is to be absorbed. He 
also finds it useful in acute cases, but not so useful as passive hyperemia 
induced by compression so applied as to temporarily obstruct the effer- 
ent veins of a part, without arresting the entry of blood through the 
afferent arteries. [He also employs suction by cupping over small 
inflamed areas, and by large glass chambers into which the affected 



MODALITIES FOR THE REACTION OF INFLAMMATION 127 

part, as the hand or foot, may be introduced and the surrounding air 
rarefied. 

Sondermann has devised an apparatus especially adapted for pro- 
ducing negative air pressure in the air cavities of the head. Brawley, 
Dabney, and Pynchon have also devised apparatuses for this purpose. 

Bier's treatment is applicable to those cases of acute inflammation in 
which the inflammatory reaction is inadequate to cope with the irritant 
noxa causing the inflammation. The treatment should not be applied 
so as to produce excessive reaction (white edema) of the tissues. It 
should never cause pain. It must not produce paresthesia or false 
sensation. In the nasal chambers it should not be kept up for more 
than one-half to one hour at a time. The mode of treatment requires 
great caution in its use, as much harm can be done with it. If white 
edema is induced, the bacteria spread through the tissues and the 
process becomes more generalized. Heat is then indicated. 

Inflammation is not yet fully understood, and until it is cases cannot 
be individualized for treatment. Wright's demonstration of antitro- 
phins, precipitins, lysins, and opsonins in the blood, and that the opsonins 
are of greater importance than the leukocytes, as the latter are depend- 
ent upon the former for their efficiency, has disturbed existing ideas to 
such an extent that there is a "shuffling of dry bones" in the scientific 
world. It appears that the leukocytes cannot digest or neutralize the 
bacteria until they have been acted upon, weakened, or rendered vul- 
nerable by the opsonins. It would seem that these researches show 
that Bier's method of inducing hyperemia does not simply flush out the 
inflamed area, but that the supply of leukocytes and antitropins causes 
a rapid removal of the dead bacteria from the field of action through 
the energized leukocytes (Adami). It appears therefore that the opsonic 
index is of even greater importance than the leukocytic index. Should 
the leukocytosis be marked and the opsonins scanty, the bactericidal 
and scavengerial properties of the leukocytes would be greatly impaired, 
and the reaction, while apparently adequate according to the older 
standard, would be inadequate according to the newer standard of 
the opsonins. (See the Opsonic Index and Vaccine Treatment of 
Infectious Diseases.) However this may be, further observations are 
necessary before the older standard is abandoned for clmical purposes. 

Technique. — In acute inflammatory diseases of the nose and accessory 
sinuses negative air pressure produced by the Sondermann, the Brawley, 
or the Dabney-Pynchon devices may be obtained as follows : 

(a) Introduce the nasal tip or tips into the anterior naris, turn on 
the exhaust power (hand bulb, water, or compressed air, according to the 
apparatus used), and instruct the patient to swallow. This brings the 
soft palate in contact with the posterior wall of the pharynx and closes 
the communication between the epipharynx and the mesopharynx. 
The air in the nose and accessory sinuses and the Eustachian tubes is 
rarefied, and liyperemia of the mucous membrane results. After a 
little practice the patient is able to maintain the state of negative pressure 
for several minutes at a time. 



128 THE XOSE AND ACCESSORY SIXUSES 

(b) The negative pressure should be alternated every three to five 
minutes with periods of rest, the whole period of treatment extending 
over fifteen to forty-five minutes. 

(c) If the treatment is attended by pain, bleeding, or white edematous 
swelling the negative pressure is too great and should be reduced. Heat 
in the form of hot air is indicated to counteract the white edematous 
swelling should it occur. 

(d) The nose-piece should be patterned after the Seigel otoscope, so 
that the mucous membrane may be inspected during the course of applica- 
tion of the negative air pressure, and if the membrane becomes pale and 
edematous, or bleeds, the treatment should be abandoned for twenty- 
four hours; that is, paralysis instead of dilatation of the vessels has 
occurred, and the nutrition of the cell structures and the local leuko- 
cytosis have been still further diminished. The method of treatment, 
therefore, requires the greatest care and intelligent application to be 
beneficial. Its careless and indiscriminate use can only produce harm- 
ful effects. The greatest objection to the mode of treatment is the ease 
of a])])lication and ease with which great harm can be done with it. 

Indicaiions. — (a) In the first five days of acute rhinitis. (6) In the 
first five days of acute sinuitis. (c) In the first five days of acute in- 
flammation of the phar\Tigeal tonsil, (d) In acute tubal catarrh, (e) 
Chronic purulent inflammation of the sinuses. In chronic cases the 
negative air pressure should be very moderate, as otherwise it might 
produce edema and white swelling and add fuel to the flames. Its 
greatest efficiency will be found in acute inflammation. In chronic in- 
flammation, either catarrhal or suppurative, heat in the form of hot air 
is a more rational mode of treatment, as it produces an active hyperemia 
and increases the cell nutrition. The negative pressure produces a passive 
hyperemia and leukocytic migration, processes much needed to promote 
speedy resolution of the inflammatory process. 

(e) When purulent secretions are present they are drawn into the 
bottle reservoir of the apparatus. In these cases the negative air pressure 
not only promotes the inflammatory reaction, but it removes the instating 
secretions as well. 

(/) The treatment should be repeated every day or every other day. 

THE OPSONIC INDEX AND VACCINE TREATMENT OF INFECTIOUS 
DISEASES. 

The opsonic index and vaccine treatment is essentially a painstaking 
laboratory process, and cannot be used as a routine mode of treatment. 
It should only be attempted, therefore, when such facilities are at the 
service of the physician. The method appears so promising, however, 
that it should be tried whenever suitable cases and expert laboratory 
control are available. The value of the opsonic index control has been 
best demonstrated in local tuberculous lesions, but it has also been 
demonstrated in a lesser number of cases in which streptococcal, 
staphylococcal, colon, and other bacterial infections are present. 



THE OPSONIC INDEX AND VACCINE TREATMENT 129 

The opsonic index is based upon the average value of a number of 
healthy non-tuberculous subjects, and is indicated as 1.0. The principle 
underlying the vaccine treatment under the guidance of the opsonic 
index is as follows: 

Certain white blood cells and endothelia are enabled to take up and 
destroy bacteria. This process is called phagocytosis. Wright and 
others have shown that these corpuscles can only do this after the bacteria 
have been acted upon by the opsonins of the blood. If the amount of 
opsonins is normal, or 1.0, phagocytosis is normally and rapidly per- 
formed; if the opsonins are below normal, phagocytosis is imperfectly 
performed. The opsonic bodies probably attach themselves to the 
bacteria, and weaken or otherwise prepare them, so that they are readily 
enveloped and destroyed by the white blood corpuscles. If, therefore, 
the opsonins are deficient, the bacteria are not sufficiently prepared for 
destruction by the white corpuscles. The opsonins appear to be an index 
of what has formerly been called the "resistance" of the cells of the body. 
Opsono is a Latin verb, which means, "I prepare for food." 

When a subject is infected by tubercle bacilli, or other pathogenic 
microorganisms, he has less than the normal amount of opsonins in the 
blood and is said to have a lowered opsonic index, or lowered resistance. 
This fact has been utilized in diagnosticating obscure hidden local 
tuberculous processes. 

Wright and others have shown that when a subject affected by local 
tuberculosis is injected with Koch's new tuberculin, the opsonic index 
first falls a little, then rises to, or above, normal. The opsonic index 
is taken daily, and after a few days it begins to fall. Wlien it has again 
receded considerably below normal another injection of Koch's tuber- 
culin is given. In this way the patient's opsonic index is maintained 
near normal, and the maximum of bacterial destruction is maintained. 
The general condition of the patient is better when the opsonic index is 
high or near normal, and it is worse when it is low. 

Too small or too large a dose of Koch's new tuberculin is ineffective. 
Indeed, too large a dose is marked by a rapid, steep fall in the opsonic 
index and the impoverishment of the patient. This shows the impor- 
tance of using the opsonic index in regulating the dosage of Koch's new 
tuberculin, and explains the various and conflicting results reported from 
its improper use. 

The serum treatment of sinuitis and mastoiditis under opsonic con- 
trol, according to J. C. Beck, affords apparently good results, though it 
is too early to foretell its ultimate place in the therapy of the infectious 
diseases of the accessory cavities of the head. The leukodescent light 
also seems to give good results, though their permanency has not been 
demonstrated. A more rational therapeutic measure is to establish 
ventilation and drainage, thereby removing the chief predisposing cause 
of infection and inflammation, and then administer the appropriate 
serum prepared from the bacteria peculiar to each case, the opsonic 
index being determined at intervals of two or three weeks. This is in 
accordance with Wright's own statement. 
9 



CHAPTER VIII. 

THE INFLAMMATORY DISEASES OF THE NOSE. 

ACUTE RHINITIS DUE TO MICROORGANISMS OF SPECIFIC FEVERS 
AND TO CONSTITUTIONAL DYSCRASIAS. 

It is a well-recognized clinical fact that the initial stage of the various 
exanthematous or specific fevers is characterized by an attack of acute 
rhinitis. Certain constitutional dyscrasias also give rise to acute rhinitis. 
The infectious or exanthematous fevers commonly characterized by an 
attack of acute rhinitis are smallpox, typhoid fever, acute articular 
rheumatism, epidemic influenza (la grippe), erysipelas, and diphtheria. 

The symptoms of all the foregoing types of specific acute rhinitis are 
about the same, except in diphtheria, where a pseudomembrane may be 
present. There are the usual manifestations found in coryza with con- 
junctivitis and photophobia. An examination of the mucous membrane 
of the nose and fauces sometimes shows an eruption quite similar to 
that found on the skin. 

The treatment should consist in the use of mild alkaline solutions with 
an atomizer or a nasal douche. The objection to the douche is the 
possibility of carrying the infection to the middle ear should the patient 
happen to swallow while the fluid is in the nose. The nose should be 
irrigated three or four times daily. 

The constitutional dyscrasias which cause acute rhinitis are acute 
articular rheumatism, diabetes mellitus, and scorbutus. In diabetic 
rhinitis the symptoms when present rise and fall with the percentage of 
sugar in the urine. Scorbutic rhinitis is associated with infantile scurvy, 
and is characterized by an excoriation about the nasal orifice. 

The treatment should be addressed to the relief of the local nasal 
symptoms and to the improvement of the constitutional dyscrasias. 



ACUTE RHINITIS. 

Symptoms. — Acute coryza; cold in the head. 

Definition. — Acute rhinitis is an acute inflammation of the nasal 
mucous membrane, characterized by chilly sensations, lassitude, nasal 
discliargc, and a swelling of the mucous membrane of the nose. The 
patient also complains of a stuffiness of the nose and sneezing. 

Etiology. — The chief predisposing cause of acute rhinitis in adults is 
an ol)structive lesion of the nasal septum, which predisposes to the local 
growth of the padiogenic bacteria and the development of their toxins, 



ACUTE RHINITIS 131 

hence the inflammatory reaction in the form of an acute rhinitis. The 
ridge or other deviation of the septum impinges upon, or is closely approxi- 
mated to, the inferior nasal concha (inferior turbinated body), thus 
interfering with drainage and ventilation of the nose and accessory sinuses. 
When the anterior portion of the septum is thus deformed it obstructs 
the breathway, and each descent of the diaphragm acts like the piston 
valve of a syringe and rarefies the air in the nasal chamber posterior to 
the obstruction. The negative pressure thus created causes the blood 
to fill the vascular tissue of the swell bodies on the inferior and middle 
turbinals, hence the stuffiness of the nostrils. Furthermore, the me- 
chanical irritation caused by the pressure of the ridge or other deviation 
against the turbinals still further aggravates the irritation and swelling 
of the mucous membrane. The secretions are thereby increased in 
quantity and changed in character. 

Inquiry usually elicits the statement that the patient (if an adult) 
has been inclined to chronic rhinitis; indeed, a complete examination 
often shows the patient to have been subject to acute exacerbations of a 
chronic rhinitis, and that a septal deformity is present. Septal deformity 
is not, however, always present, hence each case should be studied 
for the peculiar etiological factors back of it, so that the treatment for 
the ultimate cure and prevention of the acute exacerbations may be 
intelligently directed. 

Another very common cause of acute rhinitis is an imbalance in 
the vasomotor nervous system. There is a paralysis of the vasocon- 
strictor muscle fibers of the capillaries or an irritant in the blood which 
affects the dilator fibers. 

The paresis and irritation may be due to the presence of uric acid and 
its kindred products or to other acquired dyscrasia. The imbalance 
of the vasomotor nervous system may. also be due to the inadequate 
ventilation of the living and sleeping rooms, offices, etc., or to the wearing 
of improper clothing. The removal from the country to the city is often 
followed by frequent attacks of acute rhinitis on account of the changed 
conditions of living. In the country the houses are less tightly con- 
structed and but partially heated, whereas in the city the houses are more 
tightly constructed and either overheated or, as is often the case, is 
underheated in all its rooms. In either event the conditions are worse 
in the city dwelling, as fresh oxygen is a negligible quantity on account 
of the poor ventilation. Then, too, while resident in the country much of 
the day is spent in the open air, whereas in the city it is spent in 
crowded and illy ventilated offices and shops. It is obvious, therefore, 
that rliinitis due to poor ventilation should be treated by changing the 
mode of living to one which keeps the patient in the open air or in a well- 
ventilated residence and business buildings. 

The causative relationship of clothing to acute rhinitis is unf[uestioned, 
though it is difficult to describe the exact mode of clodiing that predis- 
poses to rhinitis. It may be said, however, that clodiing which favors 
perspiration is vicious. There is normally some evaporation of moisture 
from the bodv, hence the underwear should be of such material as to 



132 THE NOSE AND ACCESSORY SINUSES 

readily absorb it. The function of underwear is twofold, namely, 
(a) to retain the body heat between it and the skin; (6) to absorb the 
excess of perspiration. If, therefore, the clothing is of such density 
that it causes undue perspiration, and of such material that it does not 
absorb it, the conditions are favorable for the development of acute 
rhinitis, even though the septum is normal. Wool retains the body heat, 
but is a poor absorbent. Cotton is neither a good heat retainer nor an 
absorbent. Linen is a fair heat retainer and a good absorbent. In some 
cases wool retains too much heat and induces profuse perspiration. A 
garment of wool and cotton, or wool and linen, or of thin linen under a 
hglit woollen garment, seems to be suitable to the proper protection of 
the body. Linen mesh in some cases is insufficient protection during 
the winter months for some people, whereas it is worn with the greatest 
comfort and satisfaction by others throughout the year. It should be 
determined in each case whether the rhmitis is due, in part, at least, to 
excessive protection and perspiration, or to deficient absorption of the 
perspiration. Then, too, the question extends to the external garments 
worn both in and out of doors. For the sake of convenience the outer 
garments should be lessened or added to as the exposure to the tempera- 
ture and weather demands, while the undergarments should be of 
moderate weight and capable of absorbing the visible and invisible 
perspiration. 

A preexisting chronic rhinitis is a common factor in the causation of 
acute rhinitis, especially in adults, whereas infants and young children 
are more susceptible, and often have colds in tlie head without a pre- 
existing chronic rhinitis. 

As stated in Chapter VI, mflammation is almost always of bacterial 
origin, the conditions necessary for the growth of the bacteria being a 
lowered vitality of the cells of the tissues. I also stated that mucous 
membrane-lined cavities with blocked drainage and ventilation were 
especially subject to infection and inflammation. Trauma, chemical 
injury, and shock also lower the cell vitality and prepare the soil for 
infection and inflammation. Exposure to cold and draughts are com- 
mon sources of shock that result in acute coryza or inflammation of the 
nasal mucous membrane, hence obstructive lesions of the nasal septum 
are not always present in patients subject to acute coryza. Certain 
constitutional diseases, as diabetes, rheumatism, etc., reduce the vitality 
of the mucous membrane of the nose and accessory sinuses, and are, 
therefore, predisposing causes of this disease. All conditions, local 
and general, which lower the vital resistance of the mucous membrane 
of the nose act as predisposing causes to infection and inflammation of 
the nasal mucous membrane. I W'ish to emphasize again the fact that 
in many instances the chief predisposing cause of acute coryza (acute 
infectious inflammation of the nasal mucous membrane) is an obstruc- 
tive lesion of the septum. The influence of exposure to cold, draughts, 
foul air, poor ventilation of houses, offices, etc., have heretofore been 
given undue prominence, to the neglect of nasal stenosis (partial and 
complete), which so often bears an important relation to this disease. It 



ACUTE RHINITIS 133 

follows that chronic rhinitis is often present in persons subject to recurrent 
attacks of coryza, a condition which still further lowers the vitality of 
the nasal mucosa and predisposes to the growth of bacteria and the 
development of their toxins, which excite the inflammatory reaction known 
as acute coryza, acute rhinitis, and a "cold in the head." 

In emphasizing these facts I do not wish to obscure or belittle the 
other factors that reduce the vitality of the tissues and which predispose 
to the acute inflammatory disease. I only wish to give a true perspective 
to the underlying causes of acute coryza, so that in the treatment a more 
rational basis of procedure may be adopted. 

Acute rhinitis undoubtedly has an infectious origin, the foregoing 
etiological factors predisposing to the mfection. 

Nasal polypi and other morbid processes within the nasal chambers 
also predispose to rhinitis. 

Pathology.- — The vasomotor constrictor muscle fibers of the capillaries 
are paralyzed and the dilator fibers irritated, and, as a consequence, there 
is a passive hyperemia of the venous capillaries and lymph vessels, 
and the nose becomes "stuffed." There is also an increased migration 
of leukocytes and a transudation of lymph and serum. The production 
of mucus is temporarily checked, but later is increased. The epithe- 
lium is exfoliated and admixed with the other inflammatory products 
and secretions. 

During the first stage the secretions are greatly reduced in quality or are 
entirely absent. In the second stage the secretions are at first serous, 
and later become thick and viscid from the excessive degeneration of 
the goblet and glandular epithelial cells. In the third stage the secretions 
are mucopurulent or purulent in character. 

The duration and course of the inflammatory process varies. The 
natural history of the average case is completed in from eight to ten days, 
though under appropriate treatment it may be greatly shortened. 

Symptoms. — ^The symptoms are, for clinical purposes, divided into 
three groups, as follows: 

First Stage, or Onset. — ^The patient experiences a sense of dryness or 
prickling in the nose, with itching at the inner canthi of the eyes. Chilly 
sensations and a feeling of malaise are complained of. Examination 
shows the mucosa to be red and hyperemic, but not fully turgescent. 
The mucous membrane is abnormally dry and free from secretions. 
Headache is usually present, and there is a sense of fulness between 
the eyes. This stage lasts but a few hours. The temperature ranges 
from 100° to 103°. 

Second Stage. ^ — This stage is characterized by a profuse serous dis- 
charge and turgescence of the mucous membrane. In some cases the 
headache and the sense of fulness between tlie eyes are diminished, 
whereas in others it is increased, depending upon the patency or closure 
of the ostei of the accessory sinuses. In those cases in which there is a 
marked deviation of the nasal septum in the region of the middle turbinal 
the obstruction of the ostei on one side may be great and the pain and 
sense of fulness correspondingly increased on tliat side. 



134 THE XOSE AXD ACCESSORY SIXUSES 

Third Stage. — This stage is characterized by a mucopurulent or puru- 
lent (lischai'ge and by a marked decrease in the temperature. The 
headache and the sense of fulness between the eyes may be diminished 
so as to amount to a dull heavy feeling across the forehead and between 
the eyes. If the nasal accessory sinuses are also markedly involved in 
the inflammatory process the frontal headache and the sense of pressure 
are correspondingly pronounced. If the sinuses are not involved these 
symptoms may be entirely absent. Dizziness and vertigo also may be 
present if the sinuses are involved. The use of the eyes m reading, 
sewing, or at the theatre often produces headache and other evidence of 
ocular irritation when the sinuses are involved in acute rhmitis. 

Prognosis. — The natural duration of acute rhinitis is from eight to ten 
days. When the sinuses are also involved the duration is extended to 
two weeks, or even longer, unless the attack is aborted by appropriate 
treatment. Some writers claim there is no curative treatment of acute 
rhinitis. I believe this to be an erroneous view, and hold that nearly all 
cases may be cured if taken sufficiently early and rational treatment is 
used. 

Treatment. — The treatment of acute rhinitis should be undertaken 
with a knowledge of the nature of inflammation and the chief predis- 
posing and active etiological factors in mind. These are (a) obstructive 
lesions; (&) lowered tonicity of the cellular structures of the nasal mucous 
membrane, and (c) the mfectious microorganisms. 

(a) If there is an obstructive lesion in the nose it should be located 
by rhinoscopic exammation. Wlien found, and demonstrated to be 
spongy or erectile tissue, local applications of cocaine, adrenalin, and 
antipyrine should be made to this region to reduce the swelling and to 
establish the patency of the nasal chambers. By so doing drainage and 
ventilation are reestablished, points of immense value in promoting the 
reaction against the bacteria and toxins causing the disease. It is not 
advisable to attempt to remove by surgical means the obstructive lesion 
during the acute symptoms, though such a procedure may well be under- 
taken after they have subsided. The retention of the secretions and the 
lack of ventilation, together with the mechanical irritation from pressure, 
aggravate the existing irritation and tend to perpetuate the reaction of 
inflammation and prolong the disease. The reaction is often inadequate 
to throw off the bacteria and their toxins, hence measures should be used 
that will promote the reaction of inflammation, which is Nature's effort 
to cure the disease. 

The question naturally arising in this connection is. How may the 
reaction of inflammation be promoted? That'is, what measures may be 
adopted that will aid in combating the bacteria and their toxins? As 
stated in the section on Inflammation, acute inflammation consists in 
three reactions, namely: (a) Increased hyperemia; (b) increased cell 
nutrition, and (c) increased migration of leukocytes. The purpose of 
these reactions is (1) to increase the vitality of the attacked tissues 
(2) to remove the bacteria and toxins, and (3) to remove the dead and 
broken-do\Mi cells. 



ACUTE RHINITIS 135 

The increased hyperemia furnishes extra food for the attacked and 
weakened cells, while the increased migration of leukocytes provides 
for the destruction and removal of the invading bacteria and the dead 
and broken-down cells. Adami has shown that in acute inflammation 
the inflammatory reaction is usually inadequate for these purposes, 
although it has generally been held that it is excessive. He advises, 
therefore, that acute inflammations be treated by such modalities as 
will promote the reaction of inflammation, rather than check it. Ac- 
cording to former formulae of thought, remedies which acted favorably 
upon acute inflammations were said to lessen the inflammatory reaction, 
whereas a more correct and scientific statement is, that the remedies 
promoted the inflammatory reaction (Nature's effort to rid the tissues 
of bacteria and their toxins) and thereby hastened the cure of the 
disease. It is with this understanding that I advise the use of such 
remedial measures as will promote the reaction of inflammation. 

The exact effect of the many drugs upon these reactions is so little 
understood that it is a difficult task to undertake to give their use a 
scientific basis. The empirical use of drugs has long been practised, and 
must doubtless continue to be practised, empirically at least, until their 
action is better understood. We know enough about a few of them to 
criticise their use in acute coryza. Adrenalin has been much used in this 
disease because it was thought that the progress of the disease would be 
affected favorably by reducing the inflammatory reaction. I believe that 
its use for this purpose is contra-indicated, because the inflammatory 
reaction is an effort to remove certain noxa or irritants from the tissues, 
and should not, therefore, be checked by the local use of adrenalin or any 
other substance. The physician should recognize the activities known 
as inflammation as forces directed against a noxious foe, and should aid 
or promote them rather than thwart or check them. The chief difficulty 
in arriving at a correct understanding of inflammation is that the results 
of inflammation are confused with the process itself. When I advise 
the promotion of inflammatory reaction, I do not mean that it should be 
made worse, that cell proliferation should be increased, that the pain and 
soreness should be increased, that adhesive processes should be encour- 
aged, etc. These are the results of inflammation, and are not essential 
features of the reaction. \¥liat I mean by promoting the reaction of 
inflammation is to use such modalities of treatment as will increase the 
hyperemia, the cell nutrition, and the migration of leukocytes. By so 
doing the irritant noxa is removed, and the cell proliferation, pain, and 
adhesive processes are quickly relieved or altogether prevented. 

Unfortunately, the treatment of acute coryza has not been systemati- 
cally treated upon the basis herein outlined, hence there is little accumu- 
lated evidence upon which to base a scientific and well-established mode 
of treatment. Science is not science until proved; hence there is no 
scientific method of treating acute rhinitis. 

While the metliods of treatment to be given are somewhat hypothetical 
and in some instances purely empirical, they have been rather extensively 
tried and have proved to be of more or less value in promoting tlie 



136 THE NOSE AND ACCESSORY SINUSES 

inflammatory reaction of acute coryza; that is, they have hastened the 
destruction of the bacteria and noxa causing the disease. 

(6) The tonicity of the vasomotor nervous system should be mam- 
tained by the administration of strychnine and arsenous acid in the usual 
tonic doses. Furthermore, the patient should have plenty of fresh air 
in his room, if it can be arranged without exposing him to a draught. 
The admmistration of aconite or belladonna may be resorted to for the 
immediate effect upon the turgescence and the secretions, especially in 
the second stage. An alcohol rub over the entire body also acts as a 
tonic to the vasomotor nervous system and increases the hyperemia of 
the arterials and capillaries, and thereby increases the nutrition of the 
mucous membrane. 

(c) ^N\n\e it has not been shown that the disease is due to a specific 
microorganism, it is evident that bacteria are the exciting cause of the 
disease. An endeavor should be made, therefore, to establish conditions 
favorable for their destruction and elimination. This is best done by 
establishing and maintainmg drainage and ventilation and promoting the 
reaction of inflammation. The use of antiseptics has no effect in destroy- 
ing the bacteria, though they do promote reaction of inflammation. Surgi- 
cal experience has shown that free drainage is of prime importance in the 
treatment of infected cavities, as, for instance, in septic peritonitis com- 
plicating a ruptured appendix. Irrigation of the abdominal cavity has 
been abandoned and simple drainage substituted, with the most brilliant 
results. The operative procedure promotes the reaction of inflamma- 
tion, and thus hastens the destruction of the infecting bacteria. The 
same principle applied to acute infectious inflammations of the nasal 
and accessory sinuses brings equally brilliant results. Hence, the mode 
of treatment described in paragraph (a) wall, in most instances, meet 
the indications. If it does not, the obstructive lesions of the septum 
(or other lesion) should be removed by surgical means at the earliest 
possible time, so as to prevent such a complication during subsequent 
attacks of acute rhinitis. 

In addition to the foregoing measures the use of the leukodescent 
lamp over the nose and eyes is recommended, to promote the reaction of 
inflammation. The light from this lamp is rich in blue violet rays, in 
addition to the heat rays, and they exert a powerful and immediate 
salutary effect upon the inflammatory process; that is, they greatly in- 
crease the hyperemia and the leukocytosis, and thus dispose of the bac- 
teria, their toxin, and the dead cells of the tissues. Having done this, 
the reaction often rapidly subsides and a cure is effected. 

A treatment with the lamp should cover a period of from twenty to 
thirty minutes, at a distance of about eighteen to twenty inches from the 
face. The light is more effective if applied over the closed eyes, as the 
tissues are soft and easily penetrated by the rays, and because the veins 
of the accessory sinuses empty into the ophthalmic vein. Hence, any 
increased flow tln-ough the ophthalmic vein favors the flow from the veins 
of the sinuses and tlie nose. As acute rhinitis is essentially an acute 
simiitis, the reaction afl'ecting the sinuses effects a speedy relief or a cure. 



CHRONIC RHINITIS WITH TURGESCENCE 137 

The above mode of treatment is based upon rational principles, 
which, for the sake of emphasis, are recapitulated here: 

(a) The establishment of ventilation and free drainage of the nasal 
accessory chambers. 

(&) The establishment of the tonicity of the vasomotor nervous system. 

(c) The promotion of the elimination of the bacteria by the drainage 
and ventilation of the nasal and accessory sinuses. 

(d) The promotion of the reaction of inflammation by the leuko- 
descent light. 

Other Methods of Treatment. — 1. The administration of full doses of 
quinine and a hot lemonade at bedtime will, in some instances, 
during the first stage, abort acute rhinitis by increasing the hyperemia 
and leukocytosis. If given during the second or third stages they are 
ineffective. This method is not so efiicacious as the one given above, 
but is worth trying. 

2. Ten grains of Dover's powder and a hot mustard foot bath at bed- 
time promote the reaction of inflammation to a considerable degree, and 
during the first stage may abort the disease. During the second and 
third stages it is more difficult to promote the reaction of inflammation, 
hence this mode of treatment is not powerful enough to be of much value. 

3. The administration of rhinitis or coryza tablets, containing quinine, 
belladonna, and morphine, during the first stage will in a number of 
cases abort acute rhinitis. One tablet should be given every twenty 
minutes until dryness of the nose is produced. 

4. Aconite administered hourly in the first stage in 1 minim doses 
until dryness of the throat or tingling of the fingers is produced will 
sometimes abort the disease. During the second and third stages the 
remedy is of little use. 



\i.. [ CHRONIC RHINITIS WITH TURGESCENCE. 

Synonyms. — Alternating stenosis; simple chronic rhmitis. 
|3| Definition. — Chronic rhinitis with turgescence is characterized by 
fugitive swelling or turgescence of the swell bodies of the inferior tur- 
binated bodies, the patient complaining of attacks of nasal obstruction 
and a thick mucous discharge. 

Etiology. — ^The causes of rhinitis are given under the etiology of acute 
rhinitis, and will not be repeated in detail here. It should be stated, 
however, that in most cases there is a deviation of the septum in its lower 
and middle portion. The deviation may also be an anterior one near the 
vestibule of the nose in the cartilaginous portion of the septum, thereby 
producing anterior nasal stenosis. With each descent of the diaphragm 
the air is rarefied posterior to the obstruction, and a negative pressure in 
the nasal chambers results. The blood in the mucous membrane lining 
the nasal chambers is thus determined to the venous plexuses (swell 
bodies) of the turbinals, and turgescence or engorgement results. 

In the section on the Deviations of the Septum I have shown that 



138 THE XOSE AXD ACCESSORY SIXUSES 

obstructive lesions in the region of the inferior turbinal act in such a 
way as to produce engorgement of the tissues without much irritation. 
Hence, the effect at first is simply one of turgescence, which in the course 
of years of increased nutrition results in hypertrophy or hypertrophic 
rhinitis. If, in addition to the local turgescence, there is an associated 
obstruction in the region of the middle turbinal, the retention and de- 
composition of the secretions in the superior meatus and the posterior 
ethmoidal cells cause a prolonged low-grade irritation which may result 
in a hyperplasia of the mucous membrane, not only of the middle turbinal, 
but of the inferior as well. As an obstructive lesion of the septum in 
the middle turbinal region often co-exists with the obstructive ridge or 
spur in the inferior tin-binal region, hyperplasia or hyperplastic rhinitis 
affecting the inferior and middle turbmals is often present, ^^^len, 
however, the upper obstruction is absent, the rhinitis is usually of the 
turgescent or hypertrophic type. 

Pathology. — In the early stage there is a distention of the venous or 
cavernous tissue of the conchse (turbinals). If the inflammatory^ process 
continues a true hypertrophy or hyperplasia of the tissues takes place 
on account of the increased nutrition from the large blood supply. 

Symptoms. — The symptoms are chiefly referable to transient stenosis 
of the breathway of the nose. In addition, the secretions are heavier; 
that is, the mucoid element is increased, while the serous element 
may be decreased in quantity. The patient believes there is an actual 
increase, whereas, as a matter of fact, there is probably a decrease in 
the amount of secretion. The apparent increase is due to the increased 
consistency of the secretion, which renders it less absorbable by the 
ingoing current of air. In a normal nose the secretions are compara- 
tively thin or serous and are largely absorbed for physiological purposes 
in the lower respiratory tract. 

The transient stenosis is either intermittent or alternating; that is, 
both sides may be stenosed for a period and then open, or the stenosis 
is on one side and changes to the other. These symptoms are quite 
characteristic of turgescent rhinitis. 

The objective signs of turgescent rhinitis are chiefly found in the evi- 
dences of the engorged swell bodies of the inferior turbinals. Upon 
inspection by anterior rhinoscopy the outline of the inferior turbinal 
is smooth and bag-like, whereas, in true hypertrophy, hypertrophic 
rhinitis it is firm and unyielding. The application of cocaine or adrenalin 
shrinks the mucous membrane covering the inferior turbinal, whereas, in 
hypertrophic rhinitis there is little or no shrinkage. 

The secretions are mucoid in character, and when the swell bodies are 
contracted strings of mucous extend from the septum to the inferior 
turbinal. 

A spur or ridge is usually present upon the lower portion of the septum, 
causing ()])struction in some degree in the region of the inferior turbinal. 
The cartilaginous portion of the septum may also be deflected, thereby 
causing anterior nasal stenosis and a consequent rarefaction of the air 
within the nasal chambers with each inspiratory current. 



CHRONIC RHINITIS WITH TURGESCENCE 



139 



Epistaxis is also occasionally complained of. The ridge or crest of the 
septum projects into the inspiratory tract, and is thereby subjected to 
excessive evaporation of the secretions accumulated upon it. The dried 
crusts are blown or picked off, tearing the underlying epithelium and the 
capillary vessels, hence the epistaxis. 

Cough may or may not be present, and is due to an associated bron- 
chitis or to a nasal reflex. 

A posterior examination of the nasal choanse may reveal an enlarge- 
ment of the swell bodies upon the posterior ends of the middle and 
inferior turbinated bodies. The enlargement has often been likened to 
a mulberry. It is nodular in outline and of a grayish-blue color. 

Prognosis. — If allowed to run its course, true hypertrophy of the tissues 
in the region of the swell bodies occurs. Under appropriate treatment 
the disease is curable. 




Method of moistening a thin pledget of cotton with cocaine or adrenahn solution, a, the 
solution in an inverted bottle; b, the pledget of cotton. 

Treatment. — The treatment should be twofold in character: (a) The 
removal of the predisposing causes, and (6) the control of the immediate 
symptoms. 

(a) The removal of the predisposing causes is usually accomplished 
by the correction of the deviated septum. (See Treatment of Deviations 
of the Septum.) When this is done the negative air pressure in the nasal 
chambers disappears and the blood ceases to be determined to the 
mucous membrane, and the tendency to intermittent and alternating 
stenosis is greatly reduced. The operation of election should be deter- 
mined according to the type and location of the deviation of the septum. 

(b) The palliative treatment should be addressed to the immediate 
control of the distressing symptoms, namely, the stenosis and the heavy 
secretions. The transient stenosis may be controlled by the use of the 
electric or chemical cantorv or bv incisino- the turo-escent swell bodies. 



140 



THE NOSE AND ACCESSORY SINUSES 



Electrocauterization. — The teclmique of electrocauterization is as fol- 
lows: 

(a) Induce cocaine anesthesia by the application of a 4 per cent, solu- 
tion of cocaine on a thin pledget of cotton to the swollen free border 
of the inferior turbinal for a period of ten minutes (Figs. 89 and 90). 

(6) Turn on the electric current until the point of the cautery electrode 
is of a bright cherry-red color. 

(c) Introduce the electrode into the nasal chamber cold and place it 
on the free border of the interior turbinal (Figs. 91 and 92). Then 
move it backward and forward, while still cold, until sure of its correct 
position. Maintain the to-and-fro motion and press the contact spring 
of the cautery handle for one or two seconds, when the contact should 
be broken. The to-and-fro motion should be continued until the elec- 
trode is cold, that is for two or three seconds after the spring contact 
is broken, and then it should be removed from the nose. 




Method of applying the pledget of cotton to the inferior turbinated body, a, the pledget of 
cotton after being moistened with the cocaine or adrenalin solution is engaged upon tlie tip of 
a delicate silver probe; b, the pledget of cotton being "pasted" or spread upon the inferior tur- 
binated body. 



If these instructions are followed the procedure is painless and does 
not tear the eschar from the turbinal. If the to-and-fro motion is not 
maintained before, during, and after the electrode is heated, the eschar 
will be torn off and the cautery effect lost. 

The eschar must be left in place. If bleeding follows the removal of 
the electrode, the eschar is lost and the cauterization rendered useless. 

The cauterization should be linear, and should be about one inch in 
length. The whole length of die inferior turbinal may be cauterized in 
three sittings (Fig. 93), never in one, as too great a reaction and sloughing 
may follow. 

The sittings should be from five to seven days apart. A week after 
the first cauterization the opposite side may be treated in like manner. 
At the end of another week the middle portion of the inferior turbinal 



CHRONIC RHINITIS WITH TURGESCENCE 



141 



first cauterized may be thus treated. And so continue to cauterize the 
turbinals ahernately, at weekly intervals, until the whole length of both 
turbinals has been cauterized. 

The after-treatment of a cauterized turbinal should consist in an 
immediate spray of an alkaline solution — Dobel's or Seller's solution. 




Cauterization of the inferior 
turbinated body. 



Lateral view, showing the cautery electrode in position 
for cauterizing the inferior turbinated body. 



An oily aromatic nebula should 
follow this. Prescribe Seller's 
solution for daily use by the 
patient. The wash should be 
used with a glass nasal douche 
rather than an atomizer, as the 
force of the spray might injure 
the eschar covering the cauter- 
ized surface. 

Should infection occur, gently 
pack the nose with small cotton 
pledgets saturated with a 10 
per cent, aqueous solution of 
Merck's ichthyol. Remove the 
pledget in about fifteen minutes 
and insufflate bismuth powder 

into the nose. The clothing should receive thoughtful attention and 
be regulated according to the indications. Heavy-soled shoes should be 
prescribed. 

Submucous Cauterization. — N. H. Pierce first introduced the submucous 
cauterization of the inferior turbinated body for the reduction of turges- 
cent and liyjicrtrophic rliinitis. The mucous membrane was punctured 
near the anterior end of the free border of the turbinate and a tunnel 
made with a blunt probe beneath the turgcscent membrane. A fused 
bead of chromic acid was then introduced into the artificial tunnel or 




Showing the lines for linear cauterization in tur- 
gescent rhinitis. A, B and C, representing respec- 
tively the first, second, and third cauterizations, 
which should be made one week apart. 



142 THE XOSE AXD ACCESSORY SIXUSES 

channel. M. A. Goldstein improved the instrument for this procedure, 
as shown in Fig. 94. By Goldstein's method the bead of chromic acid 
is concealed in the cannula while being introduced, the fused bead of 
acid then being thrust from the end of the cannula and withdrawn through 
the channel in the submucous tissue. 




Goldstein's cliiomic acid applicator for submucous cauterization. 

Sloughing sometimes follows this method of cauterization. Chromic 
acid is verv irritating to the kidneys and may cause nephritis. It should 
never be used in a patient already subject to nephritis, for obvious 
reasons. 

HYPERTROPHIC RHINITIS. 

Synonyms. — ^True hypertrophic rhinitis; obstructive rhmitis; hyper- 
trophic nasal catarrh; hypertrophic ozena; hypertrophy of the turbinated 
bodies; hyperplastic rhinitis. 

Definition. — Chronic hypertrophic rhinitis is characterized by a more 
or less constant stenosis of the nasal passages. The mucous memlirane 
along the free border of the inferior turbinals is usually hypertro- 
phied, and the stenosis is chiefly referable to the lower portion of the 
middle turbinal by the bowing of the septum. Such cases are, there- 
fore, sometimes complicated by catarrhal or suppurative sinuitis and 
hyperplasia. The uncomplicated cases of hypertrophic rhinitis usually 
present free and unobstructed olfactory fissures on both sides of the sep- 
tum, the obstructive lesion l)eing limited to the anterior portion of the 
cartilaginous septum, or to the ridge along the crest of the vomer. 

Etiology.— The causes of hypertrophic rhinitis are essentially those 
given under turgescent rhinitis. AMien there is an anterior devia- 
tion of the septum there is a negative air pressure within the nasal 
chambers with each inspiratory effort. The hyperemia resulting there- 
from leads to an overnutrition of the mucous membrane and especiallv 
in the region of the swell l)odies. The contact of the deviated sep- 
tum with the mucosa of the inferior turbinal irritates it and thus still 
further excites the hypertrophic process. The altered secretions add 



HYPERTROPHIC RHINITIS 143 

to the irritation and still further increase the hypertrophy of the mucous 
membrane. 

In those cases complicated by a high deviation of the septum, and in 
which there is a complicating sinuitis (catarrhal or suppurative), the 
tissue changes are somewhat modified. Instead of an hypertrophy, 
the irritating discharge from the sinuses often causes an hyperplasia of 
the mucous membrane. There may be present, therefore, both an hyper- 
trophy and an hyperplasia of the tissue. Either the hypertrophy or the 
hyperplasia may predominate. The so-called hypertrophic rhinitis 
may, therefore, be divided into two groups: (a) The hypertrophic 
variety, and (6) the combined hypertrophic and hyperplastic variety. 
This subdivision is still further justified by the clinical fact that the 
symptomatology and treatment of the two conditions are often quite 
different. The hypertrophic variety presents symptoms chiefly referable 
to the anterior and the inferior obstruction of the nose, whereas the 
combined variety presents symptoms referable to obstruction in the 
middle turbinal region as well as to the obstruction in the anterior and 
inferior portions of the nasal chambers. 

The causes of uncomplicated hypertrophic rhinitis are, therefore, 
those conditions which give rise to a chronic hyperemia of the mucosa 
and to a passive engorgement of the swell bodies. These conditions 
are the anterior and inferior obstructive deviations of the nasal septum 
and the climatic and hygienic conditions which affect the vasomotor 
nervous system. In addition to these factors, the mild infection remain- 
ing after attacks of acute rhinitis may cause the disease or contribute 
toward it. 

Pathology. — The morbid anatomy of hypertrophic rhinitis consists 
in an increased blood supply and an increase of tissue from nutritional 
causes, rather than from irritative and inflammatory causes. The part 
most frequently hypertrophied is the mucous membrane containing 
the swell bodies, as there is naturally a greater determination of blood 
to these vascular bodies. 

Symptoms. — The symptoms are chiefly those of more or less nasal 
stenosis. The secretion is usually heavier than normal, and pasty in 
consistency, although it may be comparatively thin and watery, especially 
during an acute exacerbation. 

The nasal stenosis may be limited to one side, the side of greater septal 
convexity. The inferior turbinal on the side of the concavity is often 
greatly hypertrophied, a so-called compensatory hypertrophy, although, 
as a matter of fact, it may be due to a negative air pressure within the 
nasal chamber on that side. The anterior opening of the nose on that 
side, while normal in size, is, on account of the diminished size of the 
opposite chamber, inadequate to admit air rapidly enough for phy- 
siological purposes; hence, engorgement and subsequent hypertrophy 
result. It follows that l)oth nasal passages are often more or less con- 
stantly blocked in the region of the inferior turbinal. The patient com- 
plains of stuffiness, or sense of a foreign body in the nose, and makes 
frequent but ineffectual attempts to remove it by blowing the nose. 



V '^- ^:-^^4"iJ 



144 THE NOSE AND ACCESSORY SINUSES 

Upon anterior rhinoscopic examination the inferior turbinal is ob- 
served to be enlarged and to have an irregular nodular surface. Probe 
pressure does not cause pitting, as in turgescent rhmitis, but elicits a 
sense of resistance and of thick, fleshy tissue. The application of 
cocaine or adrenalin is not followed by marked contraction of the tissue. 
Epistaxis from the dislodgement of an adherent crust upon the crest 
of the deflection occasionally occurs. 

Prognosis. — If allowed to run its natural course, hypertrophic rhini- 
tis tends to become worse rather than better. Indeed, in the course 
of time the secretions may become so heavy and so adhesive in quality 
as to be removed with great difficulty. In such subjects irritation results 
and a hyperplasia of the tissue follows. If this is allowed to progress 
the vascular and glandular tissues become enmeshed in the contractile 
hyperplastic tissue, and atrophy of the mucous membrane begins. 

If, on the contrary, appropriate treatment is instituted sufficiently 
early in the disease the prognosis is fairly good. 

Treatment.— The treatment consists mainly in overcoming the sten- 
osis and the removal of a part or all of the hypertrophic tissue. Sprays 

and douches of alkaline, antiseptic 
Fig. 95 solutious do little more than tem- 

porarily increase the reaction of in- 
flammation and relieve the symptoms 
by the removal of the altered secre- 
tions. The removal of the nasal ste- 
nosis is accomplished by the surgical 
correction of the septal deformity and 

Ily pel trophy of the mucous membrane the rcmOVal of the CXCCSsively liypcr- 
of the inferior turbinated body, a, an- , i • j j. i • i j." /-r\' n^\ /a 

terior attachment; p, posterior aUachment. trophicd turbmal tlSSUC (Fig. 9o). (See 

Removed by the author with his turbino- Obstructivc Deviations of the Septum 
tome (Fig. 100). (Dr. Henrietta Gould's ^nd the Mcthods of Correcting Devia- 
tions of the Septum.) Be assured 
that in most instances hypertrophic 
rhinitis is a surgical rather than a medical disease. Be assured, also, 
that hypertrophic rhinitis cannot be cured by sprays and other local 
medicinal applications, although they may temporarily relieve some 
of the symptoms. 

The actual cautery has been recommended for the reduction of the 
hypertrophied mucous membrane. I can only condemn it as it is in- 
adequate for this purpose. If it is used freely enough to really accom- 
plish anything, it produces excessive scar tissue, a result to be carefully 
avoided. 

Surgical Treatment. — If the hypertroj^hy is great enough to obstruct 
the nasal passages, it should be removed surgically with scissors, saw, 
spokeshave, the swivel knife, or the submucous resection of the inferior 
turl)inated bone. 

The Scissors. — The scissors are usually used for the removal of the 
hypertrophied portion of the free border of the inferior turbinated body. 
The technique is as follows: 



HYPERTROPHIC RHINITIS 



145 



(a) Induce local anesthesia by the application of a 5 per cent, solution 
of cocaine by means of a thin pledget of cotton pasted over the hyper- 
trophied area for ten minutes. 

(6) With nasal scissors (Fig. 96) cut off the necessary portion of the 
hypertrophied membrane. 




s serrated scissors. 



(c) Use no dressing except an antiseptic dusting powder. An ex- 
ception may be made, however, in favor of Pischel's collodion dressing 
if perfect dryness of the parts can be secured. 

(d) If severe hemorrhage occurs, it becomes necessary to pack the 
nose to check it. This may be done by introducing a postnasal tampon 
with Boloc's cannula (Fig. 97), or with a rubber urethral catheter and 
then pack a long strip of gauze through the anterior nares against it 
Wlien such a tampon is used it should be moistened with the com- 
pound tincture of benzoin or dusted with bismuth powder to prevent 
decomposition of the secretions. When either of these precautions is 
taken the tampon may be left in place for three or four days without 
putrefaction. 




Boloc's postnasal tampon cannula. 

I'he Saw. — ^The saw may be used instead of the scissors when it 
is necessary to remove a portion of the inferior turbinated bone with 
the hypertrophied membrane (Holmes, Vail). 

Technique. — (a) Induce local anesthesia with cocaine. 

(6) Introduce a slender nasal saw beneath the inferior turbinated 
body and saw in an inward and upward direction through it. If it is 
impossible to in.sert the saw beneath the turbinated body it may be 
introduced above it and the incision carried downward and outward 
through the tissue. 
10 



14G 



THE XOSE AXD ACCESSORY SIXUSES 



(c) Either use no dressing or use the Pischel collodion dressing when 
conditions are favorable, that is, when all hemorrhage ceases. 

llie Spokeshave. — The spokeshave may be used if it can be engaged 
posteriorly in such a position as to enable the operator to control its 
direction in cutting forward. This operation is rarely justifiable, as 
too much of the turbinate is removed by it. 

The Technique. — (a) Induce local cocaine anesthesia. (6) Make a 
linear incision along the mediosuperior surface of the inferior turbinal 




Showing the incision preliminarj' to the removal of the inferior turbinated body with 
the spokeshave or swivel knife. 






The author's >\vi\ el turbinotome. 



just at the upper margin of the hypertrophied tissue (Fig. 98). The 
incision is for the purpose of preventing laceration of the mucous mem- 
brane as the spokeshave is drawn through it. Healing is promoted by 
a clean cut. 

(c) Introduce the spokeshave (Fig. 99) at the posterior extremity 
of the turbinal if there is a mulberry hypertrophy there, or along the 
free border of it if only that portion is involved. Engage the tur- 
binated body and pull forward in such a direction as to only include the 



HYPERTROPHIC RHINITIS 



147 



hypertrophic tissue. The spokeshave should not be used unless it is 
desired to remove some bone as well as soft tissue. 




The removal of the anterior two-thirds of the inferior turbinal with the author's 
wide swivel knife (Fig. 100). 




Showing the removal of the inferior turbinal with the author's large swiAel knife. 
Fig. 103 




The elevation of the mucoperiosteum of the inferior turbiiuUcd bod.y iireparalory to the 
submucous resection of tlic bone. 



148 



THE NOSE AND ACCESSORY SINUSES 



(d) Follow the same method of after-treatment given in the previous 
operations. 




The submucous resection of the border of the inferior turbinated bone with the author's 
swivel knife. 




Removal of the severed border of the inferi-.r turbinated bone after its submucous resection 
with the author's swivel kmfe. 



Fig. 106 




Removal of the hyperplastic free border of the inferior turbinal after the submucous resection 
of the bone shown in Figs. 103 to 105. The fleshy border is not thus removed, except when 
very pendulous, as it shrinks greatly upon being sutured. (Beck's method.) 



HYPERTROPHIC RHINITIS 149 

The Swivel Knife. — The author's large swivel knife (Fig. 100) may 
be used with even greater advantage than the spokeshave, as it can be 
made to engage or leave the tissue at any desired point along the free 
border of the turbinal. The knife used for this purpose is especially 
designed with a view to its width and strength. Otherwise it is similar 
to the one used in the submucous resection of the nasal septum. 

The Technique. — (a) Induce local cocaine anesthesia. 

(6) Insert the swivel knife as though it were a spokeshave and force 
the blade into the turbinate posterior to the hypertrophied tissue (Figs. 101 
and 102). ^Tien it has sufficiently engaged in the tissue pull it forward, 
as in the spokeshave operation, and disengage it by directing it downward 
toward the floor of the nose when the anterior limit of the hypertrophy 
has been reached. The preliminary incision of the membrane is Un- 




Sohema showing the technique of making a continuous suture of the mucous membrane jBaps 
after the submucous resection of the inferior turbinated bone. a, the shpknot at the posterior 
end of the turbinated body — the suture thread should be eighteen inches long, so that the slip- 
knot may be arranged outside of the nasal chamber and then pulled into position; h b, the curved 
needle on a fixed handle; c, the hook for pulling the thread e through the needle wounds in the 
flaps, and from the eye of the needle. When the thread is thus liberated the needle is reversed 
and removed from the nose. It is again threaded with e and another stitch taken. Four or five 
stitches are sufficient to coapt the edges of the flaps. When all the stitches are made introduce the 
hook / and exert tension upon each stitch, beginning with the posterior one. At the same time 
keep up tension on the proximal end of the thread e. In this way the whole length of the 
wound may be closed. Fix the anterior end of the suture by a knot. Remove the suture on 
the third day. 

necessary, as the cutting edge of the blade is concave and prevents 
laceration of the mucosa. Bone, as well as soft tissue, may be removed 
with it. 

(c) The after-treatment should be the same as in the other operations. 

The Submucous Resection of the Inferior Turbinated Bone. — Dr. J. C. 
Beck has developed the following technique for the reduction of 
enlarged and obstructing inferior turbinals: 

(a) Cocaine anesthesia. 

(h) Make an incision through the mucous membrane at the anterior 
end of the inferior turbinated body (Fig. 103). 

(c) Introduce a small blunt probe or elevator through the incision and 
elevate the mucous membrane from the turbinated bone on its median 
and external surface (Fig. 103). 



150 THE XOSE AXD ACCESSORY SINUSES 

(d) Introduce the swivel knife through the anterior incision into the 
mucous pouch and engage the turbinated bone, and sever it as shown in 
Fig. 104. 

(e) Remove the bone with small dressing forceps (Fig. 105). 

(/) If this does not sufficiently reduce the size of the turbinated body, 
a portion of the hypertrophied membrane may also be removed with 
scissors (Fig. 106). In some cases the submucous removal of the bone 
alone will be sufficient to overcome the stenosis. 

When the hypertrophied mucous membrane is also removed it is good 
practice to close the wound with sutures, as they prevent hemorrhage 
and the absorption of septic matter. Dr. Beck's method of suturing 
within the nasal cavity is simple and quickly accomplished, and is as 
follows : 

(g) A short curved needle set at right angles to the shank of the in- 
strument is introduced into the nasal chambers as far as the posterior 
end of the incision. The needle is then passed through both edges of 
the cut membrane, the thread caught with a small hook, and the needle 
withdrawn. For further description of the suture see Fig. 107 and the 
accompanying legend. 



HYPERPLASTIC RHINITIS. 

Synonyms. — The same as given under hypertrophic rhinitis, as the 
two conditions are often confused. 

Definition. — Hyperplastic rhinitis is characterized by an increase 
in the thickness of the mucous membrane and its contents as a result of 
prolonged mild irritation by the secretions from the sinuses. It differs 
from hypertrophic rhinitis in its causation and in its morbid anatomy. 
In hypertrophy there is an increase in the size of the cells from over- 
nutrition, whereas in hyperplasia there is an increase in the number of 
cells, and especially of the connective-tissue cells, from the slight but 
prolonged irritation. 

Etiology. — The chief causes are pressure, or the close approxima- 
tion of the septum to the middle turbinal, the resultant retention 
of the secretions, and the inflammation of the obstructed sinuses. The 
septum does not, in all cases, impinge upon the middle turbinal, and is 
not, therefore, a constant etiological factor in producing the hyperplasia. 
The sinuses may be diseased independently of the septal deviation, and 
may thus be the primary cause of the hyperplasia. In either event 
the irritation resulting from the secretions constantly flowing over the 
nnicous membrane of the middle and inferior turbinals causes the morbid 
changes in these structures. The secretion is not necessarily purulent, 
but, on the contrary, is often serous or mucous in character; that is, 
the inflammation in the sinuses may not be suppurative, but may be 
catarrhal in c-haracter. 

Symptoms. — The symptoms of hyperplastic rhinitis are often com- 
plex, as the disease is often associated with a catarrhal or a suppurative 



HYPERPLASTIC RHINITIS 151 

inflammation of the ethmoidal, sphenoidal, and possibly the frontal 
sinuses. 

The symptoms arising from the hyperplasia are those of nasal 
obstruction, especially in the region of the middle turbinal; that is, 
there is more or less nasal obstruction and a sense of stufiiness or of 
pressure in this portion of the nose. The handkerchief is frequently 
used in an effort to dislodge the secretions and to overcome the sense of 
stuffiness. Wliile the secretions may be thus removed, the stuffy feel- 
ing remains, as it is due to the contact of the turbinate with the septum. 

The secretions may be either serous or mucopurulent, depending largely 
upon the complicating disease of the sinuses. 

Anterior rhinoscopy shows the inferior turbinal to be enlarged, paler 
than normal, although it may be red and boggy, and somewhat nodular 
in outline. If the septum is deviated, and it usually is, a ridge corre- 
sponding to the crista nasalis and the crest of the vomer may be present 
on one side, while there is a bowing of the septum toward the opposite 
side in the region of the middle turbinal. The septum is also often 
thickened in its upper portion on both sides, thereby obstructing both 
olfactory fissures. 

If an empyema of the ethmoidal cells (cellulse ethmoidales) is present, 
pus may be seen in the olfactory fissure as well as in the lower portion 
of the nose. If there is catarrhal ethmoiditis the anterior end of the 
middle turbinal may be red and boggy in texture. Patients with this 
type of ethmoidal inflammation sometimes complain of soreness or of 
fissures in the skin at the margin of the vestibule. 

The subjective symptoms are due to obstructive lesions and to the 
disease in the accessory sinuses of the nose. 

The obstruction in the upper part of the nose gives rise to a sense of 
stuffiness and of pressure across the bridge of the nose. These symp- 
toms are rather constant, as the tissue enlargement is permanent. 

The obstructive lesion in the upper portion of the nose gives rise to 
the additional symptoms of headache and vertigo peculiar to sinus 
inflammation; that is, there is headache in the frontal region limited 
to, or more pronounced on, one side, and to a feeling of soreness or 
tenderness of the eyeball upon ocular movements. The stooping posture 
increases the headache, and temporary vertigo is often thereby produced. 
The headache is also sometimes referred to the temporal, vertexial, and 
occipital regions. 

The symptoms given in the above paragraph are due to the sinuitis, 
and are not always present in hyperplastic rhinitis. They are, however, 
often present, as a careful examination of the patients will show. 

Prognosis. — ^The prognosis of hyperplastic rhinitis is not as favor- 
able as that of hypertrophic rhinitis. The etiology is more complex 
and the disease more serious, and it entails more extensive surgical 
procedures for its eradication. If the diseased processes are allowed to run 
their natural course, they may eventuate in an atrophy of the mucous 
mem]:)rane, especially of the middle and inferior turbinated bodies, 
tliough there is but slight tendency (o atrophy in hypertrophic rhinitis. 



152 



THE XOSE AXD ACCESSORY SIXUSES 



If the treatment is instituted sufficiently early, the atrophic process 
may be checked and the stenosis and sinus disease eradicated. 

Treatment. — The treatment of hyperplastic rhmitis should have 
two grand objects, namely: (a) The removal of the obstructive lesion. 




Casselberry's plain scissors. 



whether it be a deviation of the septum or the hypertrophic tissue of 
the middle or inferior nasal conchse (middle or inferior turbinals); 
and (b) the cure of the catarrhal sinuitis, if present, whether it be in the 
ethmoidal and sphenoidal, or the frontal and maxillary sinuses. 




The removal of the anterior end of the middle turbinated body with Casselberry's scissors. 

Hyperplasia of the inferior nasal concha (inferior turbinal) may be 
removed by any one of the operative procedures described under hyper- 
trophic rhinitis. 

Hyperplasia of the middle nasal concha (middle turbinal) may be 
removed with the scissors and snare, the author's turbinal knife (Figs. 
]()(), 17.'^ and 174), or with the swivel knife. 



HYPERPLASTIC RHINITIS 
Fig. 110 



153 




Griinwald's right-angle forceps ■ may be used to complete the removal of the turbinate 
instead of a snare. 




Holmes' middle turbinal scissors. 



154 



THE NOSE AND ACCESSORY SINUSES 



The Scissors and Snare. — The technique is as follows: 

(a) Induce local anesthesia with a 10 per cent, solution of cocaine. 
A weaker solution is often inadequate in hyperplastic tissue. 

(b) Grasp the anterior attachment of the middle nasal concha 
(middle turbinal) with the scissors (Fig. 108) and make an incision 
about one inch in length thus severing the attachment of the anterior 
one-diird or one-half of the middle turbinated body (Fig. 109). 




The removal of the anterior half of the middle turbinated body with Holmes' scissors. 

(c) Introduce a cold wire loop over the detached portion of the 
turbinal and cut it off at the posterior limit of the incision, or sever the 
detached portion of the turbinal with Griinwald's forceps (Fig. 110). 
Still more tissue may be removed if necessary. 




Tlie anterior half of the middle turbinal removed with Holmes' scissors, exposing 
tlie bulla ethmoidalis. 



Holmes' Scissors. — With Holmes' scissors (Fig. 112) the snare is not 
necessary, as the blades are so curved that the cut made with them 
extends backward and downward until it emerges from the tissue (Figs. 
113 and 114). 



HYPERPLASTIC RHINITIS 



155 



The Swivel Knife. — The technique of the removal of the middle tur- 
binal with the swivel kiiife differs from that employed with the same 
instrument in the removal of the inferior turbinal. 




The author's narrow swivel kmie placed at the anterior attachment of the middle turbinal 
preparatory to removing it as shown in Fig. 116. 

The technique is as follows: (a) Induce local anesthesia with a 
10 per cent, solution of cocaine applied on a thin pledget of cotton over 
the whole of the middle turbinal. It may be necessary to apply a 20 to 
30 per cent, solution with a delicate cotton-wound applicator to the less 
accessible areas. 




Tlie removal of the middle turbinal with the author's narrow swivel kr 



(b) Introduce the swivel knife and engage the anterior attachment 
of .the middle turbinal (Figs. 115 and 116), so that one prong tip is 
above and the other below the attachment. 

(c) Carry the swivel blade backward with short strokes until the whole 
or a part of the middle turbinal is severed from its attachment. The 
severed middle turbinal does not pass between the prongs of the instru- 



156 THE NOSE AND ACCESSORY SINUSES 

ment, but is pushed downward beneath them. If only a portion of the 
middle turbinal is to be removed, the swivel blade is directed downward 
through the turbinal at the desired point, or, failing in this, the swivel 
knife is removed and the loop of a snare is engaged over the detached 
fragment and the removal completed. 

Remarks. — The swivel knife is not of universal use for turbinec- 
tomy or turbinotomy, although in many cases it is an ideal instrument 
for these purposes. In each case the instruments and mode of 
operation should be selected with reference to the conditions present 
rather than to blindly follow any described method of operating. 

(d) The postoperative treatment should consist of the insufflation of 
an antiseptic powder, and, in the case of severe persistent hemorrhage, the 
nose should be packed with iodoform, or compound tincture of benzoin 
gauze. 

Hemorrhage. — The middle turbinal is supplied with blood by the 
anterior and posterior ethmoidal arteries (A. ethmoidalis anterior et 
posterior) (Fig. 3), and hemorrhage of considerable severity may occur 
either at the time of operation or at a later period. As a matter of fact 
an oozing of blood continues in many cases for twenty-four hours. 

The danger of septicemia and of meningitis is increased by nasal 
tampons, hence it is not advisable to pack the nose except in extreme 
necessity. The packing should be done firmly but with caution, and 
the gauze should be moistened with the compound tincture of benzoin 
and squeezed until the excess of fluid is removed. 



CHRONIC RHINITIS WITH COLLAPSE OF THE ERECTILE TISSUE. 

Definition. — This is not a true inflammatory disease, but is usually 
classed as such. It is a local manifestation of a general anemia, and is 
characterized by the collapse of the erectile tissue of the nose and simulates 
atrophy in this region. 

Etiology. — Its chief cause is general anemia. Atrophic rhinitis is 
also characterized by anemia that is secondary to the conditions causing 
the atrophy. In simple collapse of the swell bodies the anemia is pri- 
mary and the collapse secondary. It is most often found in women, 
as they are more subject to anemia. It is occasionally found in gouty 
individuals. 

Symptoms. — The chief symptoms are drpiess of the upper respira- 
tory tract and patency of the nose. Upon anterior rhmoscopic examina- 
tion the inferior turbinals appear quite small, on account of the collapse 
of the swell bodies. Upon probe pressure the mucous membrane is found 
to be thin and tightly drawai over the underlying bone. The great 
space in the nasal chambers and the small size of the inferior turbinals 
at once suggest an atrophic condition, though true atrophy is absent; 
crusts and ozena are, however, absent, nor is there a history of their pre- 
vious presence. An examination of the blood shows anemia to be present. 
The sense of smell is imimpaired and ulceration of the mucosa and caries 



ATROPHIC RHINITIS I57 

of the bone are absent. The condition is always bilateral, as it is due to 
constitutional rather than local causes. 

Treatment. — ^The treatment should be directed to the anemia. It 
is necessary, therefore, to ascertain the type of the anemia by blood 
examinations and to carry out the treatment accordingly. I wish to 
suggest in this connection that an examination of the rectum will some- 
times reveal ulcerations or other pathological processes that may be the 
cause of the anemia and the resultant collapse of the erectile tissue. 



ATROPHIC RHINITIS. 

Synonyms. — Chronic dry rhinitis; simple mucous rhinitis; mucopuru- 
lent rhinitis; ozena. 

Definition. — Atrophic rhinitis is characterized by a sclerotic change 
in the mucous membrane and occasionally of the underlying bone, and 
by the presence of crusts and an offensive nasal breath. The conditions 
giving rise to these phenomena are varied and often complex. 

Etiology.— The three causes generally held to produce this condition 
are as follows: 

(a) A simple atrophic process which is not dependent upon other 
local disease of the mucous membrane. Meissner holds that atrophic 
ozena (see below) is due to a primitive or broad, shallow nose, and to a 
congenital development of pavement epithelium instead of the columnar 
or mucus-producing variety. 

(6) Pressure necrosis due to excessive distention of the bloodvessels. 
This is a cyanotic congestion due to a heart lesion, the general venous 
circulatory system participating in the sluggish venous flow. The 
mucosa covering the vessels is kept upon a constant stretch, and pressure 
atrophy results, as in red atrophy of the liver. 

(c) Sclerotic atrophy due to a pre-existing sinus inflammation, during 
which there is an excessive proliferation of connective-tissue cells. These 
after a time become fibrous tissue and gradually cut off the blood supply 
and choke out the glandular and vascular structures of the membrane. 
The nutrition of the mucous membrane is diminished, and functional 
activity is diminished or destroyed. 

These and various other theories are held as to the cause, or causes, 
of atrophic rhinitis. None of them is definitely proved, although the 
one advocated recently by Griinwald, and by Vieussens, Reininger, and 
Guns at the end of the seventeenth century, has rapidly gained ground in 
popular opinion. Those who hold to this theory believe that all or nearly 
all cases of atrophic rhinitis are due to suppuration of the accessory 
sinuses of the nose, more especially the ethmoidal and sphenoidal. 
My own experience is in accord with this view. I have seen many cases 
cured or greatly relieved by attention to the accessory sinuses. The 
ozena is invariably influenced favorably. In conjunction with Dr. 
Joseph Beck I have had skiagraplis of the sinuses made in cases of 
atrophic rhinitis, and without exception the sinuses appear cloudy, as 



158 THE NOSE AND ACCESSORY SINUSES 

they do in sinuitis, i. e., their outhne is illy defined and the area of the 
cavities is opaque. This shows that in atrophic rhinitis the sinuses are 
often diseased, though it does not prove the sinus disease to be primary. 

(a) Simple Atrophic Rhinitis. — Simple atrophy may take place in the 
nasal mucous membrane as well as in mucous membranes elsewhere in 
die body. 

Etiology. — The etiology is not clear, and yet it is probable that it is 
due to the presence of some irritant in the blood, as in syphilis, tuber- 
culosis, scrofula, etc. At any rate, the trophic nervous system is in- 
volved and nutrition modified. 

Treatment. — The treatment should be addressed to the constitutional 
dyscrasias, upon the disappearance of which the atrophic and ozenic 
processes improve or disappear. 

(6) Atrophic Rhinitis Due to Pressure (Cyanotic Engorgement). — 
Etiology. — (a) There is some lesion of the heart, kidneys, liver, 
or lungs which causes a damming back of the venous blood upon 
the nasal mucous membrane, as well as elsewhere in the body. (6) 
The organs thus affected do not eliminate the waste products as rapidly 
as they should, and they are retained in the blood, where they act as 
irritants, exciting inflammatory reaction of a low grade. These two 
factors account for the phenomena knpwii as pressure atrophy as it 
occurs in the nasal mucosa. 

Symptoms. — Although there is true atrophy, the membrane is con- 
gested to such a degree that there is nasal stenosis. The mucosa of 
the nose is boggy, purplish red in color, and inflamed. The ozenic 
odor may be slight. There is an exudation from the engorged vessels, 
but it is not a true mucous secretion. The skin of the nose may be red. 
There is a sense of fulness across the bridge of the nose, and frontal 
headache is commonly present. The conjunctiva may be infected and 
attended by an overflow of tears. 

D. Braden Kyle refers to a case due to organic mitral lesion. I have 
seen a case of this character in which the whole mucosa of the upper 
respiratory tract was cyanotic; the tonsils were enlarged and markedly 
blue from cyanotic congestion. 

Prog nosis. ^Th'is depends upon the curability of the lesion giving rise 
to the cyanotic congestion. The patient had a valvular heart lesion. 

It is obvious that the treatment in such cases must be palliative only. 

(c) Atrophic Rhinitis Due to Suppurative Sinuitis. — Etiology. — All the 
causes given under the various types of catarrhal rhinitis may act as causes 
of this type of disease. The inflammation attending them is followed 
by a deposit of connective-tissue cells, which after they become organized 
cut off the blood supply and choke down the glandular tissue. The 
functional activity is gradually lost and the true mucous elements of the 
membrane finally disappear. The secretions become thick and in- 
spissated. Tliey dry upon the surface of the membrane, where, through 
biochemical changes, they develop the ozenic odor. Various theories 
have been advanced in explanation of the odor, but none of them is 
proved. 



ATROPHIC RHINITIS 159 

The following are suggestive but not conclusive: 

(a) Simple decomposition of the mucopus. 

(6) Degenerative changes in which certain fatty acids are liberated, 
giving rise to the odor. 

(c) The presence of certain bacteria, as the bacillus fetidus. 

Ozena a Symptom. — Ozena is not a disease, but a sign of certain dis- 
eased conditions. It is a "stench," and it is in this sense that it is 
used. The fetid odor is associated with an inspissated secretion, which is 
seen in the form of greenish crusts covering the whole of the nasal mucous 
membrane. There may be other peculiar conditions associated with it, 
especially in those cases in which there is marked atrophy of the mucosa. 
For example, the nose may be broad and flat, the tip somewhat elevated, 
and the blood anemic. The anemia is secondary and not primary as 
in chronic rhinitis with collapse of the erectile tissue. The absorption 
of septic material and the loss of the respiratory functions of the nose 
are probably the chief causes of the anemia. It is a well-recognized fact 
that in mouth breathing due to the presence of postnasal adenoids there 
is anemia, which quickly disappears after their removal. 

The mucous membrane becomes atrophied in the later stages, and 
after a longer period the secretion and foul odor spontaneously disap- 
pear and leave a comparatively clean but sclerotic membrane. The 
ozenic odor disappears spontaneously after a number of years, hence 
it is a self-limited symptom. The mucous membrane, however, is left 
very much damaged. Its histological character and physiological func- 
tion are changed or entirely lost. 

The sclerosis and ozena in this type of atrophic rhinitis is in all prob- 
ability due to a chronic sinuitis, or to other focalized suppurative processes, 
as has been shown by Griinwald in his work on Nasal Suppuration. 
In other words, the atrophy is not primary, but is secondary to a suppu- 
rative sinus inflammation. Indeed, nearly all cases of atrophic rhinitis 
probably fall under this category. This subdivision of atrophic rhinitis 
is, therefore, from a clinical standpoint of the greatest importance. 

The rationale of the atrophic process is generally as follows: 

The secretion from the sinuses, more particularly the frontal, eth- 
moidal, and sphenoidal, flows downward over the nasal membrane, 
where it becomes dried into crusts. It undergoes decomposition and 
irritates the underlying mucosa. There is, in addition, a mechanical 
irritation from the shrinkage and contact of the crusts with the mucous 
membrane. The chemical and mechanical irritation thus produced 
cause a proliferation of connective-tissue cells, which, when fully organ- 
ized, contract and choke out the true elements of the mucous membrane. 
Shrinkage and atrophy progress until the mucous membrane is replaced 
by a sclerotic one, devoid of mucous glands and columnar ciliated 
epithelium, pavement epithelium replacing the columnar type. 

During the progress of the atrophic process the ozena is a symptom, 
but after the true mucous membrane is destroyed the mucous secretion 
and ozena cease. Crust formation and ozena are self-limited phenomena, 
many years being required, however, to rid the patient of them. 



160 THE NOSE AND ACCESSORY SINUSES 

Symptoms. — The symptoms vary with the state of advancement 
and activity of the process. The chnical picture presents the features 
showTi in the comparative table given below. This is adapted from 
MacDonald's work on Diseases of the Nose. 

Comparative Table of the Symptoms of Atrophic Rhinitis and 
Rhinitis with Collapse. 



Chronic Rhinitis with Collapse of the Erectile 
Tissue. 

1. Chiefly in anemic women. The anemia is 

primary. 

2. No peculiarity of physiognomy. 

3. Mucous membrane anemic. 

4. Collapse of erectile tissue; no tendency to 

atrophy. 

5. No ulceration. 

6. Always bilateral. 

7. Spontaneous cure if the anemia is relieved. 



8. Olfaction not affected. 

9. No characteristic odor. 

10. Little or no incrustation; if present, is lim- 
ited to the anterior third of the middle 
turbinals. 



Atrophic Rhinitis with Sclerosis and Mxtcous 
Secretion. Ozena. 

1. Chiefly in women and children; all subjects 

become anemic. 

2. Small, sunken wide nose with wide nasal 

fossEe. 

3. Mucous membrane anemic. 

4. Collapse of the erectile tissue with tendency 

to atrophy. 

5. Sometimes there is ulceration, and necrotic 

bone if the disease is of sinus origin. 

6. Usually bilateral; may be unilateral. 

7. After some years there is a tendency to im- 

provement of the sj-mptoms. The ozenic 
sj-mptoms disappear as the atrophy be- 
comes more complete. 

8. Olfaction is often lost. 

9. Breath tj-pically ozenic. 

10. Crusts are distributed over the entire mucous 
membrane. 



Treatment. — When seen in the early stage the treatment should 
aim at (o) the removal of the causes of the inflammation that produces 
the sclerotic process, and (b) intranasal cleanliness. 

(a) The Removal of the Causes. — The causes of the inflammation 
are numerous. Some have already been considered under acute catarrhal 
hyperplastic rhinitis, chronic suppurative sinuitis, and the congenital 
primitive nose with its pavement epithelium. Other causes are trauma- 
tism, deflections, and other obstructive lesions of the septum. By the 
removal of these exciting causes of the inflammation the sclerotic process 
may be modified or stopped altogether. 

From the foregoing statements concerning focal suppuration within 
the sinuses and elsewhere in the nasal chambers, it is evident that in 
many cases the treatment should be addressed toward the cure of the 
suppuration of the sinuses, rather than to the atrophy resulting from it. 

(/;) Intranasal Cleanliness. — Intranasal cleanliness is obtained by the 
use of antiseptic douches containing a liberal amount of mild alkalies 
to soften and dissolve the crusts and tenacious mucopus. A solution 
of 8 grains of sodium bicarbonate to the ounce of water as hot as can be 
borne should be forcibly injected into the nostrils at frequent intervals 
during the day. A fountain syringe is well adapted for this purpose. 
The patient should be instructed to clear the nose by blowing after 
each injection. The injections may be administered by the physician 
at first, as the patient will not or cannot thoroughly cleanse his nose. 
To free the nostrils from crusts and tenacious mucus, a warm antiseptic 
aqueous solution of borax, sodium bicarbonate, oil of eucalyptus, carbolic 



ATROPHIC RHINITIS 161 

acid, glycerin, and alcohol should be injected into the nostrils. A two- 
ounce hard-rubber or an Alpha and Omega bulb syringe is well adapted 
for this purpose, as considerable force is necessary to dislodge the crusts. 

Personally, I prefer to pack the nose with cotton-wool saturated with 
a 10 per cent, aqueous or glycerin solution of ichthyol, which should 
be removed in from twenty to thirty minutes, the crusts being softened 
and easily detached by blowing the nose or by the use of a cotton-wound 
probe. This course of treatment, if faithfully carried out, will afford great 
relief. Mild astringent stimulating solutions, or powders, are of value in 
reducing the local infection. Powder with 5 to 20 per cent, of silver nitrate 
or a 1 to 2000 trichloracetic acid solution may be used for this purpose. 
The associated sinus diseases should be treated as described under the 
Accessory Sinuses. Indeed, this is often the only method of treatment 
attended with success. Even this fails if the atrophy is far advanced. 

Paraffin Injections in Atrophic Rhinitis. — ^Paraffin injections beneath 
the mucous membrane of the inferior turbinated body and of the septum 
have been used by several rhinologists with great improvement of the 
symptoms. The crusts are either diminished or disappear altogether. 
Most writers recommend using paraffin in melted form, although the 
danger of thrombosis is ever present. More recently paraffin has been 
used in semisolid form to obviate this danger. A special syringe (Fig. 
196), adapted to the use of semisolid paraffin, has been devised by Dr. 
J. C. Beck for this purpose. With this device the danger of thrombosis 
is reduced to the minimum. 

The injections should be made under local cocaine anesthesia. The 
amount injected at each sittmg varies with the friability of the mucous 
membrane. In some cases only one or two minims or grains should be 
injected, as to exceed this amount would tear the mucous membrane. 
In other cases as much as one to two drams may be injected. The injec- 
tions should be made at intervals of from five to ten days, enough time 
being allowed between the sittings for the subsidence of the reaction. 

Either the inferior turbinal (nasal concha) or the septum may be 
chosen for the site of the injections. The needle should be introduced 
a half-inch or more beneath the mucoperiosteum, and a small amount 
of paraffin injected. It should then be withdrawn, a quarter of an inch 
and more of paraffin injected, and so on until the needle is withdrawn. 

The effects produced are a lessening or the disappearance of the crusts, 
a thinning of the secretions, a sense of air passing through the nasal 
cliambers, and occasionally edema of the eyelids. The good effects 
have remained for a period of two years and promise to last much longer. 
The lumen of the nasal chambers is diminished, thus accounting in a 
measure for the lessened desiccation of the secretions. It is also quite 
probable that the irritation of the paraffin, a foreign body in the tissues, 
produces an increased hyperemia and leukocytosis. Whatever the ex- 
planation may be, it appears that paraffin injections beneath the muco- 
perichondrium of the nasal septum and beneath the mucoperiosteum 
of the inferior turbinal materially improves the symptoms in the so-called 
atrophic rhinitis with incrustations. In those cases wherein the sinus 
11 



162 THE XOSE AXD ACCESSORY SINUSES 

origin of the suppuration and crusts is in doubt, and wherein the patient 
refuses operative interference on tlie sinuses when they are kno\ni to be 
the focal centre of the disease, paraffin injections may be used with the 
reasonable assurance of an improvement of the symptoms. 

SUPPURATIVE RHINITIS; NASAL SUPPURATION. 
(A symptom, not a primary disease.) 

Suppurative rhinitis has been described by various authors, notably 
by Bosworth in his work on the Diseases of the Nose and Throat. 
He described suppurative rhinitis in children as a primary disease, which, 
when neglected, eventuates in atrophic rhinitis in adults. The trend 
of opinion is gradually breaking away from the view that primary 
suppuration of the nasal mucous membrane is often found. On the 
contrary, it is believed that it rarely exists except secondarily to sinuitis. 
Personally, I hold the latter view. 

Pus in the nasal chambers is present in the later stages of acute coryza, 
which is an infectious disease and is usually complicated by a purulent 
infection of the sinuses. Purulent secretions may also accompany 
syphilitic, tuberculous, and gonorrheal processes in the nose. The 
specific or exanthematous fevers are characterized by a purulent inflam- 
mation of the nasal and accessory sinus membranes. The various 
accessory sinuses, when affected by a purulent inflammatory process, 
discharge their purulent secretions into the nasal passages. Generally 
speaking, if after the nasal chambers are cleared of pus by mopping with 
a cotton-woimd applicator the pus reappears within a few minutes in the 
middle meatus, it comes from the sinuses discharging into this meatus, 
namely, the frontal, anterior ethmoidal (including the bulla ethmoidalis), 
and the sinus maxillaris (antrum of Highmore). Occasionally one of 
the anterior ethmoidal cells discharges through the inner or median wall 
of the middle turbinal into the olfactory fissure or superior meatus. 
When the pus appears in the superior meatus, it is probably from the 
sinuses opening into the meatus, namely, the posterior ethmoidal and the 
sphenoidal sinuses. An occasional exception to this is when the sinus 
maxillaris (antrum of Highmore), whose posterior and superior median 
wall is in relation to the superior meatus, discharges through a perfora- 
tion into the superior meatus. Such a condition is rare, hence pus in this 
meatus as seen in the olfactory fissure is generally indicative of suppura- 
tion of the posterior ethmoidal and the sphenoidal sinuses. It is barely 
possible that there may be a focalized ulceration of the nasal mucous 
membrane in the superior meatus, and that the pus is from the meatus 
rather than the sinuses. It appears, therefore, that nasal suppuration is 
rarely, if ever, a primary disease, but that it is always, or nearly always, 
secondary to some other disease of die mucous membrane and bony walls 
of the nasal chambers or the accessory sinuses of the nose. Suppuration 
of the nose as a primary disease will not, therefore, be described, but the 
other diseases to which it is secondary are described, and the reader is 
referred to diem for further iiiforniation. 



PLATE I 




Anterior Reconstruction. On account of the multiplicity of 
lines, the individual ethnnoidal cells are not sho\A^n; however, 
the two groups are represented, the anterior being lined hori- 
zontally and the posterior perpendicularly. The left sphenoidal 
sinus lies far above the right; its inner wall extends almost as 
far to the right as the outer wall of the right sphenoidal sinus. 
(H. W. Loeb.) 



PLATE II 




Left Lateral Reconstruction. In this and Plate I the frontal 
sinus is colored yellow, the maxillary purple, the sphenoid 
green, and the ethmoid red, the anterior group being lined hori- 
zontally and the posterior group perpendicularly. The ethmoidal 
cells are to be noted in two groups, the anterior two in number, 
and the posterior three. The first anterior cell is shown dis- 
placing the anterior wall of the frontal. The frontal is seen 
opening into the frontonasal canal. The antero-inferior wall of 
the second ethmoid constitutes the bulla ethmoidalis. (H. W. Loeb.) 



CHAPTER IX. 

THE INDIVIDUAL SINUSES. 

The sinuses are divided for clinical purposes into two groups, namely, 
the anterior and the posterior sinuses. The anterior group is composed 
of the frontal, the anterior ethmoidal and the maxillary sinuses. Hajek 
calls this group Series I. The posterior group is composed of the 
posterior ethmoidal and the sphenoidal sinuses, and is called Series II 
(Fig. 117). 

Our knowledge of the etiology, symptomatology, pathology, and sur- 
gical treatment of the sinuses has increased so greatly during the last 
ten years that it seems to be proper to depart from the traditional manner 
of presenting this subject, wherein each sinus is separately described 
and treated. As a matter of fact, a single sinus is rarely diseased, two 
or more being commonly affected at the same time. Indeed, it is not 
uncommon to find all the sinuses on one side of the head affected. The 
maxillary sinus is perhaps more often affected singly than either of the 
other sinuses. This is accounted for by the fact that in about one-half 
of the cases it is infected from the teeth rather than from the nose, whereas 
the other sinuses are nearly always infected from the nose. Having a 
common source of infection, they are, therefore, more often simultane- 
ously diseased. 

For this reason a general discussion of sinus inflammations is to be 
preferred to a discussion of each sinus individually. Nevertheless, it 
will be advantageous to present the peculiar symptoms and other con- 
siderations of each sinus separately. The following considerations are 
therefore to be read in conjunction with the general description which 
follows. 

SERIES I. 

The Frontal Sinus.— The frontal sinus is an extension upward of the 
etlimoidal cells between the plates of the frontal bone. The extension 
occurs at about the age of puberty, hence in infants and young children 
tlie frontal sinuses are absent. The size and shape of the frontal sinuses 
vary greatly in different individuals, and indeed the two sinuses often 
vary greatly in the same individual. Reference to Plates I, II, III, IV 
and V show some of the variations in the frontal sinuses, the drawings 
being taken from skiagraphs of some of the author's cases. These varia- 
tions are of surgical interest, as the difference in size will often determine 
the method of operating. If there is a large and deep frontal sinus, great 
external deformity may f()llf)\v tlic complete removal of the anterior wall. 



164 



THE NOSE AXD ACCESSORY SINUSES 



In such a siil)ject the operation may be so executed as to avoid, or to 
greatly rc(hicc, the probaliiHty of marked disfigurement. 

H. W. Lceb's projections of the sinuses (Plate I and II) show more 
clearly than any other work the relations of the sinuses to one another 




The anterior portion of the right side of the skull has been rendered transparent. A catheter is 
passed into the Eustachian tube. 1, catheter; 2, Rosenmiiller's fossa (recessus pharyngeus); 3, 
tubal fold (torus tubarius) and plica salpingopharyngea; 4, pharyngeal opening of Eustachian tube; 
5, plica salpingopalatina; 6, levator palati muscle; 7, hard palate; 8, soft palate and uvula; 9, 
external nose and naris; 10, inferior turbinate; 11, middle turbinate; 12, superior turbinate; 13, 
frontal sinus; 14, ethmoidal cells in middle nasal meatus — two ethmoidal cells appear, one above 
the other, extending to the middle turbinate; 15, ethmoid cells in superior nasal meatus; 16, 
sphenoidal sinus; 17, antrum of Highmore, seen through the interior of the nose in the middle 
meatus; 18, same in the inferior meatus; 19, mouth and lacrymonasal duct; 20, superior meatus; 
21, alveolar process with three teeth— the roots are faintly seen within the alveolar process; 22, 
roof of orbit seen in anterior fossa of skull; 23, juga cerebralia and impressiones digitata;; 24, 
lesser wings of the sphenoid with anterior cHnoid jjrocesses and optic foramen; 25, sella turcica; 
26, middle fossa of skull; 27, lamina cribosa; 28, crista galli; 29, frontal bone. (After Bruhl- 
Politzer.) 

and to the structures of the nose. The anteroposterior and lateral pro- 
jections are shown. Plates III, IV, V and VI also give a good idea of 
the distribution of the sinuses. 



PLATE III 

Fig. 1 Fig. 





Large right frontal and a small left frontal sinus 
(From author's skiagraph.) 



Absence of the frontal sinuses in a patient 
aged twenty-nine years. Small anterior eth- 
moidal cells are shown. This patient had exten- 
sive necrosis of the ethmoidal and sphenoidal 
bones, and secondary mastoiditis complicated by 
a brain abscess in the motor area for the arm 
and leg. The arm and leg on the opposite 
side were partly paralyzed. The ethmoidal and 
sphenoidal sinuses, mastoid and brain abscess 
were successively operated upon without result. 
(Author's case.) 





Very large frontal sinuses. (From author's 
skiagraph.) 



Very large irregular riglit front: 
frontal sinus. (From aull... 



rid a small left 
skiagrai.h.) 



The Distribution of tlie Frontal Sinuses as Shown by 
Skiagraphy. 



PLATE IV 





Large frontal sinuses and an anterior ethmoidal 
cell extending well over the right orbit. (From 
author's skiagraph.) 



Narrow longitudinal frontal sinuses, the right 
havTng an ethmoidal cell encroaching upon its 
floor. (From author's skiagraph.) 





Very large left frontal sinus, almost divided by 
a septum. The left sinus e.xtends about one-half 
inch beyond the median line. (From author's 
skiagraph.) 



Large right frontal sinus with an anterior eth- 
moidal cell (bulla frontalis) encroaching upon its 
floor. (From author's skiagraph.) 



The Distribution of the Frontal Sinuses 
Skiagraphy. 



as Shown by 



PLATE V 





Side view of frontal sinus with great depth and 
upward extension. A small anterior ethmoidal 
cell, the bulla frontalis (see Fig. 117), encroaches 
upon its floor. (From author's skiagraph.) 



Another large frontal sinus with marked back- 
ward extension over the orbit. (From author's 
skiagraph.) 





Side view of the frontal sinus with limited up- 
ward extension and moderate backward extension. 
(From author's skiagraph.) 



unusual downward extension of the frontal 
sinus. (From author's skiagraph.) 



The 



Anteroposterior Extension of the Frontal Sinuses as 
Shown by Skiagraphy. 



PLATE VI 





Frontal sinus with extreme extension backward, 
and with a large anterior ethmoidal cell encroach- 
ing upon the posterior portion of its floor. 
(From author's skiagraph.) 



Side view showing absence of the frontal sinuses 
in a patient aged twenty-nine years. Anterior 
view shown in Plate III, Fig. 2. (From author's 
skiagraph.) 





Side view showing a frontal sinus of moderate 
depth. (From author's skiagraph.) 



An extremely large and deep frontal sinus, 
(From author's skiagraph.) 



The Anteroposterior Extension of the Frontal Sinuses as 
Shown by Skiagraphy. 



THE INDIVIDUAL SINUSES 



165 



Skiagraphy. — The skiagraphic plate affords good information con- 
cerning the presence or absence of disease in all of the sinuses except the 
sphenoidal if the exposure is properly made. It is not yet known what 
causes the cloudy appearance when the sinus is diseased. Coakley says 
it is not known whether it is due to the thickness of the inflamed 
membrane, to the presence of pus, or to the changed condition of the 
bone. I have a skiagraph of a patient affected with a severe chronic 
catarrhal sinuitis upon whom I performed a double ICillian opera- 
tion, in which the right frontal sinus as shown by the plate was 
cloudy, but less so than the left. Upon operating the right sinus was 
found to be free of pus, and its periosteum and mucous membrane were 
entirely gone. The bone was chalkv white and slightly roughened. 
The left sinus was free of pus, but was filled with granulation tissue and 
viscid mucous secretion. The patient had 
complained for several months of an acrid Fig. lis 

secretion which irritated the nasal mucosa. 
This case is related in this connection, as it 
is unique, and demonstrates that a frontal 
sinus devoid of membrane, periosteum, and 
purulent secretion gave a cloudy effect in 
the skiagraph, though not so pronounced as 
that given by the sinus in which the mem- 
brane and granulations were present. Pus 
was not present in either sinus. 

Tenderness upon Pressure. — Tenderness over 
the frontal bone is rarely present in frontal 
sinuitis except in very acute cases with 
obstructed drainage. Tenderness is often 
present, however, when pressure is made 
against the floor of the affected sinus near 
the inner angle of the orbital cavity (Fig. 
118). The finger tip should be placed well 
under the roof of the orbit and the pressure 
directed upward. Pain is thus often elicited 

even in chronic catarrhal cases. Tenderness in this region does not, 
however, always indicate frontal sinus disease, as the anterior eth- 
moidal cells sometimes project beneath the floor of the sinus (Fig. 143). 

When such an anatomical deviation is present the surgeon may be 
led to a wrong conclusion. This difficulty may be obviated by having 
a skiagraph made, as it will aid in determining the position and condition 
of the frontal and anterior ethmoidal cells. 

The tenderness present in frontal sinuitis is so nearly in the same posi- 
tion as that in ethmoidal sinuitis that a careful distinction sliould be made. 
In ethmoidal sinuitis the tenderness is usually located a litde above the 
median palpebral commissure (inner can thus) of the eye and a little 
deeper in the orbital cavity than the canthus. The pressure should be 
made inward toward the median line, rather than upward, as in testing 
the frontal sinus. 




The correct method of making 
pressure under the floor of the 
frontal sinus. Pressure is often 
made under the supra-orbital 
ridge, whereas it should be made 
much deeper. 



166 THE NOSE AND ACCESSORY SINUSES 

Redness and Swelling. — Redness and swelling over the frontal region 
are only present in severe acute inflammation of the frontal sinus where 
the bone is affected by an infective osteomyelitis and the skin has yielded 
to the inflammatory process. There are perhaps a hundred cases of 
frontal sinuitis in which the redness and swelling are absent to one in 
which they are present. The day is past when a surgeon should wait 
for such symptoms before deciding to operate upon the frontal sinus. 
There are other positive indications of sinus disease to guide him to a 
diagnosis and to a choice of the mode of treatment. 

Mucous Discharge. — AVliile catarrhal inflammation of the sinuses is 
generally referred to in the text-books, no clear idea of the symptomatology 
and diagnosis is given. The presence of pus in the nose has been an 
essential requirement for making a diagnosis. I have found it almost 
as easy to diagnosticate sinuitis without pus as with it. The symptoms 
are much the same as those in purulent sinuitis, except that pus is absent. 
The secretion is mucous or seromucous in character, and might easily 
escape observation. The patient may or may not complain of burning 
sensation in the anterior portion of the nasal passages, or of fissures or 
excoriations at the margin of the nostrils as a result of the acrid catarrhal 
discharge. 

Headache. — Frontal headache limited to, or originating on, the side 
affected is generally complained of. The headache is often worse 
during the night, especially upon awaking while in bed, or in the 
morning. It is often confounded with eyestrain. Headache due to 
eye-strain is generally relieved upon closing the eyes, especially upon 
retiring for the night. The headache caused by frontal sinuitis (catar- 
rhal or suppurative) is not aggravated by attendance upon the theatre; 
whereas if due to eye-strain, it is thereby aggravated. 

Dizziness; Vertigo. — Dizziness or vertigo of slight degree is present 
in most cases, severe in others. It is often present in simple catarrhal 
inflammation, as well as in suppurative inflammation of the frontal and 
ethmoidal sinuses. It is especially aggravated by stooping, or, if in a 
stooping posture, upon assuming the erect posture. Careful inquiry is 
often necessary to elicit this symptom, as the patient does not consider 
it of any significance. 

Ocular Symptoms. — According to Fish, Zeim, Wood, Stucky, Coffin, and 
others (Eye in Relation to the Sinuses), inflammation of the frontal or 
any other sinus may give rise to morbid processes in any of the structures 
of the eye. This is accounted for by the free anastomosis of the veins of 
the sinuses with the ophthalmic vein. Congestion in the sinuses causes 
a like condition in the eye. Infection is thereby favored; papillitis, 
choroiditis, optic neuritis, iritis, keratitis, etc., thus becoming established. 

Intracranial Complications. — Extradural and brain abscess, meningitis, 
and sinus thrombosis may arise from sinuitis. Inasmuch as the 
posterior wall of the frontal sinus is thinner than the external or anterior 
wall, it is curious that intracranial complications are so rare. The 
superior longitudinal and the cavernous sinus occasionally become 
tlirombosed in frontal sinuitis. Meningitis of sinus origin is more 



THE INDIVIDUAL SINUSES 



167 



frequently reported now than formerly, a fact significant of a better 
understanding of the subject. 

The Anterior Ethmoidal Sinuses.^ — The anterior ethmoidal cells vary 
in number from two to eight, and are smaller than the posterior cells. 
They all drain into the middle meatus. According to Logan Turner, the 
frontonasal canal opened in the infundibulum in about one-half of the 
specimens examined, and directly into the middle meatus in the remainder. 
The anterior cells are separated from the posterior cells by a thin trans- 
verse bony partition. The attachment of the middle turbinated body to 
the external wall of the nose also marks the line of division between 
the anterior and the posterior group of cells. The anterior cells lie in 
front of and below it, while the posterior cells lie above and behind it. 
Clinically the two groups of ethmoidal sinuses are, therefore, divided into 
anterior and posterior cells. The anterior cells belong to Series I, while 
the posterior cells belong to Series II. 





Fig. 119. — Empyema of tlie ethmoidal sinuses with perforation through the lacrymal plate at 
the inner canthus of the right eye and marked bulging at this point. Both upper eyelids are 
edematous and purple. The right eye is entirely closed, the left almost. One year previously 
had a similar attack following scarlet fever. (Author's case.) 

Fig. 120. — Same case six days after operation. External wound gradually filled in by granu- 
lation and became closed in two months. (Author's case.) 



Accessory ethmoidal sinuses are sometimes present in the middle 
turbinal and in the uncinate process, and when present drain into the 
middle meatus and belong to the anterior group or Series I. 

The upper wall of the ethmoidal cells is a rather dense but thin plate 
of bone. The cribriform plate is not covered by the cells, but is freely 
exposed in the attic of the nose. While the bone is dense and not 
easily fractured by ordinary force exerted during an operation, its 
numerous openings render it a possible atrium of conveying infection to 
the meninges. The outer wall of the ethmoidal sinuses is the os ^planum 
or lamina papyracea of the ethmoidal and the lacrymal bones. These 
plates of bone are extremely thin, and form the inner wall of the orbital 
cavity. Should this plate of bone be perforated, orbital cellulitis, with 
protrusion of the eyeball, might result. 

In Fig. 119 is shouoi a ca.se of ethmoidal suppuration in which the 
lacrymal bone was carious and perforated. When first seen there was 
a large nipple-like projection of the skin at the inner angle of the orbit. 



lOS THE XOSE AXD ACCESSORY SIXUSES 

or lateral wall of the nose, in this region. The right eyelid was swollen 
and closed, while the left was less swollen and partially closed. The upper 
and lower lids of both eyes were discolored purple. Protrusion of the 
eyeballs was absent, as orbital cellulitis was not present. Had the per- 
foration occurred more posteriorly through the os planum, orbital cellu- 
litis would in all probability have occurred. 

The patient had a similar attack one year previous to this one. The 
swelling subsided, but the nasal discharge continued, and the eye was 
uncomfortable. 

Skiagraphs showed marked cloudiness in the ethmoidal region on the 
right side, while on the left it was less cloudy. The frontal sinuses were 
absent, or if present were very small. The lower meatus of the nose was 
quite open. Frontal headache and dizziness were prominent symptoms. 

The nipple-like projection was incised at once and discharged a half- 
ounce of thick yellow pus. On the following day, under general anes- 
thesia, the region was exposed by an external skin incision extending 
from a point below the nipple-like tumefaction to the middle of the right 
eyebrow. The lacrymal bone was almost entirely destroyed by necrosis. 
The frontal process of tlie maxilla was removed with rongeur forceps, 
thus fully exposing the anterior ethmoidal cells to operative interference. 



The author's ethmoid curette. 

The entire ethmoidal labyrinth, including the middle turbinal, was re- 
moved with a curette (Fig. 121). The curette was also used through the 
anterior nasal opening, to make sure that no remnants of the cells were 
left. The cranial plate and the os planum were carefully but thoroughly 
curetted until they were smooth. 

The left side was operated through the nose, the middle turbinal and 
the edunoidal cells being removed in their entirety, in so far as they could 
he reached with the curette by this route. 

Fig. 120 shows the patient one week after operation. The edema and 
discoloration of the eyelids have entirely disappeared, and the wound 
in the lacrymal region on the right side permits of a clear view of the 
interior of the nose. The marked change m the facial expression is 
suggestive of the improved condition of the patient. The purulent 
secretion may penetrate the orbital plate, as shown in Fig. 122, and 
cause orbital cellulitis. 

The Maxillary Sinus (Antrum of Highmore). — ^The maxillary sinus, 
the third and last sinus belonging to Series I, is the largest, and, 
according to the prevailing opinion, is more frequently diseased than 
either of the other sinuses in both series. Personally, I question this 
statement, as according to my own observations the ethmoidal and 
frontal sinuses are more frequently involved. Our knowleflge of the 



THE INDIVIDUAL SINUSES 



169 



symptomatology of sinus diseases in general has greatly increased 
during the past five or ten years, with the result that ethmoidal, sphenoi- 
dal, and frontal sinuitis are diagnosticated twenty times where they were 
once ten years ago. While the antrum still holds an important rank as a 
seat of disease, the ethmoidal and the frontal occupy an equally important 
place. The diagnosis of antral inflammation has been understood for 
many years, and this has given rise to the impression that it is much more 
common than inflammation in the other sinuses. It may be infected 
from the nose or the teeth, the cases probably being about equally divided 
between these two sources of infection. On account of the dental origin 
of so many cases of maxillary sinuitis, it is 
more often affected singly than either of the 
other sinuses, in which the infection is almost 
always of nasal origin. When the infection 
is of nasal origin quite naturally more than 
one group of sinuses is simultaneously af- 
fected. 

The osteum maxillare is situated in the up- 
per portion of the naso-antral wall as far away 
from the floor of the sinus as possible. This 
apparently renders the drainage of the secre- 
tions quite difficult or impossible, except as 
they overflow when the antrum is filled. This 
is not the case, however, as there is but little 
secretion in the sinus in health — only enough 
to keep the mucous membrane moist. The 
epithelium of the antral mucous membrane 
is of the modified ciliated columnar variety, 
though it is but slightly developed and in 
patches. The wave-like motion of the cilise 
aids in carrymg the scanty secretions to the 
osteum maxillare at the top of the sinus, 
where it is discharged through the infundib- 
ulum into the middle meatus. 

In the course of severe or long-continued 
inflammation of the mucous membrane of 
the antrum the cilise are injured or destroyed 
altogether, and the secretions are retained in 
the antrum because they are not carried to the ostium maxillare. The 
secretions are greatly increased in quantity, a fact that still further tends 
to promote the accumulation within the sinus. 

The second bicuspid and the first and second molar teeth are in 
close relation to the floor of the sinus. Indeed, they sometimes project 
into tlie bony cavity, l)eing only covered by mucous membrane. A 
suppurative process around the root of either of these teeth might 
easily affect the mucous membrane of the sinus through the lymphatics 
and bloodvessels. Indeed, an affection of tiie crown of the teeth may 
extend through the lymphatics to the antrum. 




Showing the thin orbito-etli- 
moidal wall partially destroyed. 
During etlimoiditis this wall may 
be broken or perforated, and give 
rise to orbital cellulitis. (Au- 
thor's specimen.) 



170 THE NOSE AND ACCESSORY SINUSES 

The superior wall or roof of the sinus is crossed in its central portion 
by the infra-orbital nerve, which lies in a groove on the broad mferior 
side of the plate of bone. It is covered by mucous membrane and may 
be easily injured during the curettement of the sinus. 

As it is a nerve of sensation rather than of motion, it regenerates readily 
after being injured, even if long portions of it are removed. Motor 
nerves do not thus readily repair. 



SERIES II. 

Series II is composed of the posterior ethmoidal and the sphenoidal 
sinuses, and their ostei open into the superior meatus of the nose. 

The Posterior Ethmoidal Sinuses. — The posterior ethmoidal are 
usually fewer in number and larger in size than the anterior ethmoidal 
cells. Sometimes they occupy nearly all the ethmoidal labyrinth, ex- 
tending to the anterior portion of the nose, and sometimes the anterior 
cells extend backward almost to the sphenoid bone. 

The ostei open into the superior meatus and are in relation to the 
posterior half of the middle nasal concha (turbinated body), upon which 
the secretions flow\ As the middle turbinal slopes slightly dowTiward and 
backward, the secretion flows toward the posterior choana, though it also 
flows over the median border of the turbinal through the olfactory fissure, 
or space between the turbinal and the septum, hence a purulent secretion 
in the olfactory fissure is usually indicative of posterior ethmoidal suppu- 
ration. It may, however, indicate sphenoidal disease, or a combined 
empyema of the ethmoidal and sphenoidal sinuses. The secretions may 
also be forced into this position from the middle meatus by snuffing the 
nose. 

The ostei of the posterior cells are not visible by either anterior or 
posterior rhinoscopy, nor are they accessible to the probe or cannula. 

The symptoms of posterior ethmoidal suppuration are not so distinct 
as those in either of the cells comprising Series I. As the posterior 
cells are deeply situated, external tenderness is not present. Exoph- 
thalmos may result from the retention of the purulent secretion in the 
cells, the os planum forced outward behind the eyeball, causing it to 
protrude forward. This also gives rise to diplopia and strabismus 
and to a circumscribed visual field, especially for colors. The ocular 
disturbances are extremely rare in proportion to the number of cases in 
which the posterior ethmoidal cells are diseased. According to my 
own clinical observations, the ethmoidal sinuses (anterior and posterior) 
are more often diseased than the maxillary sinus, which is generally 
regarded as the most frequently affected. The ethmoidal sinuses are so 
situated in the upper and narrow portion of the nasal chambers, where a 
moderate deviation of the septum or an enlargement of the middle tur- 
binal closes the olfactory fissure and thus blocks ventilation and drainage 
of the superior meatus and accessory cells. For these reasons the 
])osterior ethmoidal cells are often the seat of disease. 



THE INDIVIDUAL SINUSES 171 

The secretion in the posterior portion of the olfactory fissure is sig- 
nificant of ethmoidal suppuration, though the pus may come from the 
sphenoid. Indeed, the posterior ethmoidal and sphenoidal cells are so 
closely associated that when one is diseased both are often affected. A 
postrhinoscopic examination showing purulent secretion on top of the 
middle turbinal is almost certain evidence of disease of the posterior 
ethmoidal and sphenoidal cells. Crusts and secretions in the vault of the 
epipharynx are likewise indicative of the same affection. 

The Sphenoidal Sinus. — ^The ostium sphenoidale is situated in the 
anterior wall of the sphenoidal sinus near the top of the cavity, though it 
is occasionally a little lower down. It is near the septum of the nose and 
is hidden from view by the close approximation of the middle turbinal 
to the septum. If there is marked atrophy of the turbinal, or if the sep- 
tum deviates to the opposite side, it may be seen by anterior rhinoscopy. 
The opening varies from ^ to 4 mm. in diameter. 

The purulent secretion flowing from the ostium either drains directly 
through the posterior choana into the epipharynx or on to the posterior 
end of the middle turbinal. Ocular inspection can usually only be 
made after the removal of the entire middle turbinated body. 

The pain or headache occurring in sphenoidal inflammation is usually 
referred to the occipital region on the affected side, though in some cases 
it is diffused and ill defined. Catarrhal inflammation causes the same 
headache as suppurative inflammation, though it may not be so severe. 

The ocular symptoms usually ascribed to suppuration of the sphe- 
noidal sinus are those dependent upon the compression of the optic 
and oculomotor nerves. The optic nerve passes over the roof of the 
sinus, hence in closed empyema in which the thin bony wall of the roof 
softens, compression if not actual destruction of the optic nerve may 
take place. If only optic neuritis occurs, this is followed by atrophy 
and blindness. If the pressure reaches the sphenoidal fissure, the oculo- 
motor nerves, the third, fourth, and sixth, become involved and strabis- 
mus in some form follows. Intense neuralgia may result from a neuritis 
of the ophthalmic division of the fifth nerve. 

Other ocular lesions arising in the course of inflammatory diseases of 
this and all the other sinuses have already been referred to in the Eye 
in Relation to the Sinuses. 



DIFFERENTIAL DIAGNOSIS. 

To illustrate the methods of difl^erential diagnosis, a series of hypo- 
thetical cases will be given, assuming the symptoms characteristic of 
the simple and combined empyemas of the various sinuses in the open, 
closed, and latent forms. 

Simple empyema refers to those cases limited to one group of cells, 
as the maxillary sinus, frontal, anterior ethmoidal, posterior ethmoidal, 
or the sphenoidal sinus. 

Open empyema refers to an ompyema, either simple or coml)ino(l, in 
which the ostei are open and permit of driiinage and ventilation. 



172 THE NOSE AKD ACCESSORY SINUSES 

Closed empyema refers to those eases in wliieli the ostei are closed by 
pathological changes and the secretions are retained and cause pressure. 

Latent evipijema refers to tliose cases in which the ostei are open but 
the secretion is so slight that it is not demonstrable, except by irrigation 
of the affected sinus. 

The ostei of the sinuses are so situated that they drain into either the 
middle or die superior meatus of the nose. The sinuses situated an- 
t(M-iorly drain into die middle meatus, while those situated posteriorly 
drain into the superior meatus. 

The anterior group, or those draining into the middle meatus, are the 
antrum, die frontal, and die anterior ethmoidal cells. These have been 
designated by Hajek as Series I. 

The posterior group, or those draining into the superior meatus, are 
die posterior ethmoidal and the sphenoidal sinuses. These are desig- 
nated as Series II. For the sake of brevity and clearness these 
terms will be used. Having defined the terms, we are ready to recite a 
series of hypothetical cases, illustrative of the symptoms and procedures 
necessary to arrive at a positive differential diagnosis between empyema 
of the various sinuses or combinations of them. 

Case I. — (a) Complains of unilateral discharge from the nose. 

(6) No pain. 

(c) Subjective fetid odor. 

(d) There is an ulcer at the root of the second bicuspid tooth on the 
side of the nasal discharge. 

(e) x\nterior rhinoscopy shows pus in the middle meatus. 

The conclusion, based upon the above data, is that one or more of the 
anterior group of cells, Series I, is involved. Wliile the ulcerous 
bicuspid suggests the antrum as the sinus most probably affected, it is by 
no means proved, nor are the frontal and anterior ethmoidal sinuses 
knowm to be free. To still further differentiate the focal centre of infec- 
tion the following procedures must be instituted : 

1. Remove the secretions from the middle meatus with the douche or 
a cotton-wound probe, and place the patient in Escat's position, i. e., 
the head dirown forward with the affected side turned upward to favor 
die flow of pus from die antrum. After remaining in this position for a 
few minutes the middle meatus should be reexamined, and if pus is found 
die antrum is probably involved. This is not absolutely established, 
however, as it might have come from the frontonasal canal. To still 
further clear the diagnosis, introduce a cannula and trocar through 
the naso-antral wall in die inferior meatus (under cocaine anesthesia) 
(Fig. 123) and irrigate die antrum. If pus is found the antrum is 
involved. The diagnosis is not yet complete, as it remains to be 
demonstrated whether the frontal and anterior edimoidal cells are affected. 
If after diorough irrigation of die antrum pus does not reappear in the 
middle meatus, die probabilities are strongly in favor of a simple em- 
pyema of the antrum. This is true in view of the fact that the flow of 
])us from die frontal sinus is nearly constant, as its outlet when the 
patient is in a sitting posture is in the most dependent portion of die 



DIFFERENTIAL DIAGNOSIS 



173 



sinus. In this case pus does not reappear in the middle meatus for 
several hours, unless the patient assumes Escat's position, hence the 
condition is probably a simple empyema of the antrum. 

To still further strengthen the diagnosis transillumination of the antrum 
and frontal sinus should be performed. If the side involved shows 
opacity over the lower eyelid, a non-luminous pupil, and the absence 
of the sense of light with the eyes closed, empyema of the antrum is 
indicated. If, in addition, transillumination of the frontal sinus is 
negative, the diagnosis of a simple empyema is fairly well established. 

The anterior ethmoidal cells are still to be considered. Transillu- 
mmation does not help us here. The bulla ethmoidalis belongs to the 
anterior ethmoidal cells, and if it is enlarged toward the septum, or 
downward against the uncinate process, it is probable that the anterior 
ethmoidal cells are involved. 

Fig. 123 




Introducing a trocar and cannula into the maxillary antrum beneath the inferior turbinal 
for diagnostic purposes. 



If pus is removed by irrigation from the anterior ethmoidal cells, 
the case is one of combined empyema of the antrum and anterior 
ethmoidal cells. If it is also removed by irrigation from the frontal 
sinus, the case is one of combined empyema of Series I. Skiagraphy 
shows the frontal and ethmoidal areas clear. 

Case II. — (a) Unilateral discharge of pus from the nose. 

(h) Dull aching pain in the left cheek bone. 

(c) Pus in the middle meatus. 

(d) Slight tenderness over the cheek bone on pressure. 

(e) Case under observation for several days; pus not always found in 
the middle meatus. 

( /') Outer nasal wall on left side bulges toward septum. 

((/) Pus occasionally discharged in great quantities, after wliicli the dull 
ache in the malar region is relieved. 

After performing the procedures described in Case I the purulent 
secretion is excluded from the frontal and an'erior ethmoidal cells, and 
is localized in the antrum. The diagnosis is a simple closed empyema of 



174 THE NOSE AXD ACCESSORY SINUSES 

the antrum. Tlie retention of the purulent secretion gives rise to the 
pain and tenderness over the left cheek bone and to the bulging of the 
outer nasal wall toward the septum. At times the pressure of the puru- 
lent secretion was great enough to force it either through the ostium 
maxillare or the accessory ostia, which were closed by the swollen 
mucous membrane. The pain caused by the pressure was relieved after 
each spontaneous discharge. This was a case of closed empyema of 
the antrum. 

Case III. — (o) No nasal discharge. 

(6) There is a previous history of nasal discharge from the right side. 

(c) Frequent attacks of frontal headache on the right side. 

(d) ]\Iental depression. 

(e) Aprosexia. 

(/) Transillumination of antrum and frontal sinus is negative. 

(^) Pus not present in either the middle meatus or the olfactory slit. 

(h) Irrigation of the sinus through a puncture in the inferior meatus 
(Fig. 123)^shows a very small amount of pus. 

(i) Irrigation of the frontal and anterior ethmoidal cells is negative. 

(j) Irrigation of antrum continued until pus disappears. 

{k) Supra-orbital pain, mental depression, and aprosexia disappear. 

Diagnosis. — Latent empyema of the maxillary sinus. 

Case IV. — (a) Unilateral nasal discharge. 

(6) Supraorbital pain and tenderness on percussion. 

(c) Pressure on the roof of the orbit (floor of frontal sinus) elicits pain. 

(<^) Pus present in the middle meatus. 

(e) When wiped away it reappears after a few minutes. 

(/) Escat's position of the head has no influence on the flow of pus. 

(g) Lying upon the back checks the flow. 

(h) Frontal headache beginning on the affected side, more marked in 
the morning. 

(i) Dizziness upon stooping 

(;') Transillumination shows the crescentic light over the lower eyelid, 
the red pupillary reflex, and the sense of light in both eyes with the lids 
closed. 

(k) Transillumination of the frontal sinus seems to show diminished 
luminosity on the affected side, although the difference between" the 
two might easily be accounted for by anatomical variations. 

(/) Puncture of maxillary inus through the inferior meatus negative. 

(m) The cannula is introduced into the frontonasal canal (Fig. 124) 
and irrigation through it brings pus. Pus reappears in the middle 
meatus in a few minutes. 

(n) Skiagraph shows cloudiness of the frontal sinus. 

Diagnosis. — Simple open empyema of the frontal sinus. 

Case V. — (a) Complains of constant nasal discharge, right side. 

(h) Supra-orbital headache on right side. 

(c) Tenderness and swelling over the right eyebrow. 

(d) Anterior rhinoscopy. Septum deviated to right, in the region of 
the middle turbinal. Polypi in middle meatus on right side. 



DIFFERENTIAL DIAGNOSIS 175 

(e) Probe shows polypi attached to uncinate process and the middle 
turbinal. 

(/) Series I involved, probably localized in the frontal or the 
frontal and anterior ethmoidal sinuses. 

(g) Transillumination, maxillary sinus, faint crescent and pupillary 
reflex. Frontal opaque. 

(h) Polypi removed. 

(i) Maxillary sinus punctured through inferior meatus and odorless 
pus is washed out. 

(j) Frontal irrigated through cannula. Pus abundant. 

(k) Frontal irrigated daily, maxillary sinus occasionally; absent in 
maxillary after the first irrigation. 

(I) At end of six weeks frontal sinus still discharges pus. 

(m) Radical external operation; caries and polypi found in frontal 
sinus. 

Diagnosis.— Empyema of frontal sinus with secondary involvement of 
the maxillary sinus, which acts as a reservoir, but is not a focal centre of 
disease. 

Case VI. — (a) Complains of purulent crust formations in right 
nostril and in the epipharynx in mornings. Hawks up crusts from the 
epipharynx. 




Frontal sinus cannula. 

(6) Dull headache variously located; sometimes it is frontal, then 
vertexial, and then occipital. 

(c) Mental depression and aprosexia. 

(d) Anterior rhinoscopy: Septum deviated to right in region of 
middle turbinal. Olfactory slit narrow and filled with pus and crusts. 
Small polypi springing from the border of middle turbinal. 

(e) Posterior rhinoscopy shows purulent secretions flowing over the 
posterior end of the right middle turbinal and the posterior epipharyn- 
geal wall. Crusts not found, as they form at night when the position 
of the head and the quietness of sleep favor accumulation. 

(/) Middle meatus free from pus. 

{g) Provisional diagnosis: Empyema of Series II. 

(h) A cannula is passed into the sphenoidal sinus through its ostium. 
Irrigation shows no pus (Fig. 131). 

(?") A curved silver probe introduced through the olfactory slit shows 
bare rough bone in the superior meatus. 

Diagnosis. — Open empyema of the posterior ethmoidal cells. The 
irrigation of the sphenoidal sinus eliminates it from consideration, 
and as Series II is only composed of the sphenoidal and posterior 
ethmoidal sinuses, the empyema is located by exclusion in the posterior 



176 THE NOSE AND ACCESSORY SINUSES 

ethmoidal cells. This is still further substantiated by the presence of 
rough, bare bone in the superior meatus. 

Case \ll. — (a) Complains of the formation of crusts in the epipharynx; 
also of postnasal "dropping." 

(6) A subjective sense of odor is present, even in the absence of such 
an odor. 

(c) Vertexial and occipital headache. 

(d) Field of vision, especially for colors, diminished. 

(e) IVIental depression. 

(/) Anterior rhinoscopy; olfactory slit occasionally filled with pus, 
though it is usually clear. 

(</) Probing shows the mucous membrane of the superior meatus 
intact, while probing of the sphenoid sinus shows roughened bone and 
bleeding. 

(h) Posterior rhinoscopy; purulent secretions on posterior end of 
right middle turbinated body and upon the posterior wall of epi- 
phar^'nx. 

(i) Irrigation of the sphenoidal sinus shows pus in considerable 
quantities. 

(j) Transillumination of maxillary and frontal sinuses negative. 

(k) Examination of the fundus oculi shows slight papillitis. 

Diagnosis. — Open empyema of Series II, probably focalized in 
the sphenoidal sinus. If the treatment of the sphenoid is followed 
by the disappearance of all symptoms, the diagnosis is positive. If the 
purulent discharge continues the posterior ethmoidal cells should be 
removed, and if a cure follows, the diagnosis of combined empyema of 
the sphenoidal and posterior ethmoidal sinuses is established. 

Case VIII. — (a) Complains of intense vertexial and occipital headache. 

(h) Also of crust formation and postnasal dropping, yellow in color. 

(c) Subjective sense of odor. 

(d) Sudden blindness in the right eye. 

(e) Great mental depression and aprosexia. 
(/) Dizziness complained of. 

(g) Anterior rhinoscopy shows pus and crusts in the olfactory fissure. 

(h) Transillumination of the maxillary and frontal sinuses is negative. 

(i) Probing of the middle and superior meatuses is negative. 

(j) Cannot locate the ostium of the sphenoidal on account of the great 
swelling. 

(k) Middle turbinal is removed and the ostium sphenoidalis appears 
to be filled with granulation tissue bathed in pus. 

(Z) The anterior wall of the sphenoid is removed, the cavity 
curetted, and granulation tissue and pus are found in considerable 
quantities. 

(m) After the removal of the middle nasal concha (turbinated body) 
no pus is seen coming from the region of the posterior ethmoidal cells. 

Diagnosis. — Simple closed empyema, granulations, and caries of the 
walls of the sphenoidal sinuses on the right side. 



DIFFERENTIAL DIAGNOSIS 177 

The sudden blindness is accounted for by pressure upon and inflamma- 
tion of the optic nerve, or by venous stasis or thrombosis of the ocular 
veins. 

The upper wall of the sinus may be softened and bulging against the 
optic nerve, thus inhibiting its function. 

Case IX. — (a) Complains of supra-orbital, vertexial, and occipital 
headache. 

(6) Also of purulent discharge from the right nostril into the 
epipharynx. 

(c) Subjective sense of odor. 

(d) Strabismus of the right eye. 

(e) Transillumination shows opacity of the right lower eyelid (left 
negative) and absence of red pupillary reflex, also opacity over the right 
frontal sinus. 

(/) The bulla ethmoidalis is enlarged downward and inward. 

Provisional diagnosis of empyema of Series I and II is made. It 
is still a question as to the exact localization of the suppuration. It 
seems probable that all the sinuses in Series I and II are involved, 
although not yet proved. 

(g) The blunt probe is used, and shows bare, rough bone in the superior 
meatus and in the region of the uncinate process (the inner and inferior 
lip of the hiatus semilunaris). This makes it quite probable that the 
posterior ethmoidal, anterior ethmoidal, and the antrum are involved. 
When the bulla ethmoidalis is enlarged downward the discharge of pus is 
blocked in the infundibulum and is pent up in the anterior ethmoidal 
and the frontal sinuses. The pus under these circumstances often breaks 
through the lateral wall of the nose into the antrum. The enlargement 
of the bulla (one of the anterior ethmoidal cells) is in itself significant of 
a diseased process in this group of cells. 

(Ji) The anterior end of the middle turbinal and polypi in the middle 
meatus are removed. 

(i) The maxillary sinus is irrigated through a puncture in the inferior 
meatus and much pus removed, but persists in discharging. 

{]) The frontal sinus is irrigated through a cannula and a copious 
discharge of pus follows and persists. 

(k) The bulla is broken down with a curette, and pus wells from its 
interior. A polypus also protrudes from its cavity. The middle tur- 
binal is resected and the posterior ethmoidal cells are thoroughly re- 
moved by curettement. After a time the pus discharge from the region 
ceases. 

Having demonstrated the persistent presence of pus in all the 
sinuses embraced in Series I and II a positive diagnosis may be 
made. 

Diagnosis. — Combined empyema of all the accessory nasal sinuses 
of one side of the head. A radical external operation and intranasal 
operations may or may not be indicated. All the sinuses may be drained 
by operative procedures through the nose and a cure eft'ccted without 
external operations in many cases. 
12 



178 THE XOSE A\D ACCESSORY SINUSES 

Note. — While the foregoing .series of hypothetical cases does not 
exhaust the list of possible and actual combinations of empyema of the 
accessory nasal sinuses, it illustrates fairly well the data and methods 
of procedure necessary to arrive at a diagnosis. Nor should it be 
understood that the data used in the above series is in strict accord with 
the clinical aspect of every case having the diagnosis given above. Other 
symptoms and pathological conditions are found, and great anatomical 
asynnnetry often comjjlicates the diagnosis. What is given above is in 
the main true. Much that is left unsaid is also true. It is obvious 
that in a limited number of hypothetical cases all the clinical and 
pathological data cannot be given. 



CHAPTER X. 

GENERAL CONSIDERATIONS IN REFERENCE TO THE SINUSES. 

The nasal accessory sinuses are the residual remains of the olfactory 
organ as found in some of the lower animals whose sense of smell is very 
acute. In the process of evolution the large distribution of the olfactory 
nerve has become less and less necessary, hence the sinuses are being 
gradually closed off from the nasal chambers until only small openings 
are present in man. Inflammation of the lining mucous membrane 
of the walled-off spaces becomes, therefore, an important pathological 
process. If the sinuses were more open to ventilation and drainage, an 
inflammatory process within them would be of less importance, because 
the perpetuity and destructiveness of the process depend very largely 
upon the lack of normal ventilation and drainage. It follows, therefore, 
that when inflammation of the sinuses is present the first principle of 
treatment is to establish ventilation and drainage of the involved sinuses. 
This may only mean that the swollen and inflamed mucous membrane 
around the cell openings should be depleted by the application of adre- 
nalin, cocaine, or antipyrine, or it may mean that some surgical procedure 
should be instituted for their relief. However this may be, hold fast 
to the idea that ventilation and drainage of the sinuses is of prime impor- 
tance, and that the removal of the morbid material is secondary to this. 

Etiology. — The etiology of the inflammatory diseases of the nasal 
accessory sinuses of the nose, like that in other mucous lined cavities 
of the body, is largely embraced in those conditions which interfere with 
the drainage and ventilation of the cavities. (See Etiology of Inflamma- 
tions of the Nose and Accessory Sinuses, Chapter VI.) When there is 
good drainage and ventilation, inflammation is rare, except in those cases 
subjected to a virulent infection or the resistance is lowered by some 
dyscrasia. The local expression of a constitutional dyscrasia, as 
syphilis, tuberculosis, etc., or a carious process in some contiguous 
organ, as a tooth, may cause sinus inflammation, even though the 
drainage and ventilation of the cells is normal. Aside from these and 
other local and constitutional diseases which cause sinus inflammation, 
it may be said that the anatomical configuration of the interior of the 
nose, whereby the drainage of tiie secretions and the ventilation of the 
sinuses are interfered with, plays an important role in the etiology of sinus 
inflammation. 

The constitutional diseases having most to do in the causation of 
sinuitis are syphilis and tuberculosis. When there is a granulomatous 
infiltration in the outer wall of the nose, the ulcerative process may 



180 TIIK XOSE AM) ACCESSORY SIXUSES 

invade the sinuses and give rise to inflammatory symptoms, as pain, 
tenderness, suppuration, headache, (Hzziness, etc. Likewise, when 
tuberculous inhhration and subsequent degeneration is focahzed in the 
out(M- wall of the nose, the sinuses may participate in the process, or 
the ostei of the sinuses may become closed from swelling of the mucous 
membrane, thereby obstructing the drainage and ventilation. 

Diseases of the contiguous anatomical structures, as the teeth, hard 
palate, and outer wall of the nose, may give rise to inflammation of the 
mucous membrane lining of the sinuses by an extension to these cavities, 
and by l)locking die cell openings so that drainage and ventilation is im- 
paired or altogether lost. 

Caries of the root of a tooth located beneath the floor of the maxillary 
sinus (antrinn of Highmore) may cause empyema of the antrum by 
infection through the carious fistula thus formed, or by way of the 
vessels and lymphatics. It has been estimated that nearly one-half of 
all empyemas of the antrum have their origin in diseased teeth, while 
the lemainder are due chiefly to intranasal diseases and anatomical 
tleformities of the nose. Nasal polyp is also regarded as a cause of sinus 
inflannnation, although I believe the polyp is more often the result, 
rather than the cause, of sinuitis. However this may be, it is certain that 
the presence of a nasal polyp aggravates an existing sinuitis, and that 
its removal is often attended by an apparent rather than a real cure of 
the sinus inflammation. 

Foreign bodies in the nasal passages may cause sinuitis by erosion 
and subsequent infection of the nasal mucosa, by directly blocking 
the cell openings, or by erosion through the outer nasal wall into the 
sinuses. 

Nasal operations may eventuate in sinus inflammation by reactionary 
inflammation and infection, which may extend directly through the outer 
nasal wall or via the cell openings into the sinuses. In hospital practice 
particularly, infection from other patients may give rise to a sinuitis. 

Nasal dressings may cause a damming up of the secretions which 
undergo decomposition and infection, and thus give rise to sinus inflam- 
mation. Too much emphasis cannot be laid upon the untoward 
results of intranasal tamponing, as it is a fruitful source of inflammatory 
disease of the nasal and sinus mucous membranes. Personally, I have 
abandoned intranasal dressings except in those cases where there is 
severe hemorrhage and where a dressing must be introduced to hold the 
septinn in position after certain operations for the correction of deviations. 
Even then they should not be left in position an hour longer than is abso- 
lutely necessary to accomplish their purpose. 

Venous stasis from intranasal pressure may cause sinuitis. The press- 
ure may be due to some anatomical or pathological departure from the 
normal, as a deviation of the se]>tum ])ressing against tiie outer wall of 
the nose, or to gummatous swelling of the sejitum. 

These and other jxithological lesions of the adjacent structures 
may cause sinuitis. All cases should, dierefore, be carefully studied in 
order to determine the predisposing causes of the inflammation. 



GENERAL CONSIDERATIONS IN REFERENCE TO SINUSES 181 

The Exciting Causes. — The exciting causes of sinus inflammation are 
the various microorganisms causing the exanthematous and other infec- 
tious fevers. It is weh known that coryza is often one of the early 
phenomena of this disease, and that it is due to the microorganisms 
and their toxins. The inflammation usuaUy extends to the sinuses, where 
it may remain in a latent or chronic form. In some cases it is only after 
many years that the sinus involvement becomes obvious enough to attract 
the attention of either the patient or the physician. 

It is probably true that the sinus inflammation thus started is more apt 
to become chronic in those cases in which the cell openings are more 
or less blocked by anatomical deviations of the septum or other obstruc- 
tive lesions of the nose. If, for example, the septum in its upper portion 
is deviated to one side, so as to approximate to the middle turbinal, the 
sinus inflammation arising during an attack of one of the infectious 
fevers is more liable to continue into the chronic form than it would be 
if no such obstructive deformity of the septum existed. 

Pathology.— The pathological changes occurring in the mucous 
membrane and bony walls of the antrum in the course of suppurative 
inflammation are what one might expect in a mucous-lined cavity. 
Much discussion has arisen on this subject between anatomists and 
clinicians. Anatomists have found less marked changes, probably 
because they only examined such cases as came to them from the dead- 
house, while clinicians describe much more extensive changes in living 
cases, from whom specimens were removed during life, or upon the 
postmortem table. I prefer to base the pathology upon the clinical 
rather than upon the anatomical data. 

Acute inflammation of the sinuses may be divided into the exudative 
and the diphtheritic, although the latter is rarely present and is not a 
true diphtheritic membrane. 

The exudative inflammation may be serous, fibrinous, sero- 
purulent, or purulent in character, according to the intensity of the 
inflammatory process. 

For didactic purposes the changes occurring in the tissues may be 
studied in the following order, which represents the usual sequence of 
the pathological events: 

(a) The submucous tissue is infiltrated with serum, while the surface 
is dry. Leukocytes also fill the meshes of the submucous tissue. 

(b) The capillaries are dilated, and the mucous membrane is red in 
consequence. 

(c) After a few hours, or a day or two, the serum and leukocytes 
escape through the epithelial covering of the mucosa, where they become 
admixed with bacteria, epithelial debris and mucus. In some instances 
capillary hemorrhage occurs and blood becomes admixed with the 
secretions. The secretions, at first thin and watery, later become thicker 
and tenacious, on account of the coagulation of the fibrin of the serum. 

(d) In many cases resolution by the absorption of the exudate and 
the cessation of the dischai-ge of the leukocytes takes place in from 
ten to fourteen days. 



1S2 THE XOSE AXD ACCESSORY STXUSES 

(r) In otlicr casos, liowvvcr, the inflainmation passes from the catarrhal 
to the purulent type, the leukocytes l)ein<f thrown out in immense 
numl)ers. Resolution is still possible, although not so probable, as 
the tissue changes are not yet of a fixed type. Unless the process is 
speedily arrested the tissue changes become j)ermanent and chronicity is 
established. 

(/) If the ostei of the sinuses are open the discharge of pus may 
continue indefinitely with little or no j)ain. If, on the contrary, they 
are closed, the ])urulent secretion is retained, and pressure symptoms, 
as pain, swelling, and tenderness, arise. If the discharge cannot escape 
through the ostei the point of least resistance bulges before die pressure 
of confined pus. The points of least resistance vary in different cases, 
although there is reasonable constancy in their location. 

llie points of least resistance in the sinuses are as follows, due allowance 
being allowed for anatomical variations: 

(a) In the frontal sinus the inferior wall is the thinnest, especially 
three-quarters of an inch from the median line, over the anterior ethmoidal 
cells, hence the frequent involvement of these cells in frontal empyema. 
C'linically, we often see cases in which there is a sudden guslf of pus into 
the nasal chamber, after which the pain and other pressure symptoms are 
relieved. It is ])robable that in these cases the floor of the frontal sinus 
yielded to the pressure of the pent-up pus, which may have discharged 
through the anterior ethmoidal cells, although it may have escaped 
through the frontonasal canal. 

(b) In the antrum the most vulnerable point in the nasal walls is 
the pars membranaceje, the membranous portion of the middle meatus. 
The anterior and superior walls are sometimes thin, and may bulge, 
or become perforated by the pressure of the retained pus. One of the 
characteristic symptoms of antral empyema is the tenderness and swell- 
ing over the anterior (canine fossa) wall. Bulging of the upper or 
orbital wall causes an interference with the external muscular apparatus 
of the eyeball. Perforation in the orbital wall, or roof of the antrum, 
gives rise to an abscess of the orbit, or orbital cellulitis. 

(c) In the ethmoidal sinuses the point of least resistance is, perhaps, 
difficult to define, on account of the complexity of the ethmoidal laby- 
rinth, it being composed of several pneumatic spaces. The lamina 
papyraceje (j)aj)er j)late) separating the cells from the orbital cavity is 
cjuite thin, as its name implies, and maybe the seat of bulging and per- 
foration. The inner, or nasal, aspect of the ethmoidal cells is more 
(hin, and in emj)yema is distended until it presses against the septum. 
The ])ressure may extend toward the orbit and give rise to an imbalance 
of the external muscles of the eyeball, strabismus being the commonest 
expression. 

(d) In the sphenoidal sinus the point of least resistance is in the upper 
wall, or roof, which is in close relationship to the optic nerve; hence 
the ocular disturbances often found in empyema of this sinus. 

In chronic inflanunation by far the greater number of observations 
have b<>en made on die antrum, because it is more accessible to inspection 



GENERAL CONSIDERATIONS IN REFERENCE TO SINUSES 183 

through the canine fossa. There is no particular reason, however, why- 
similar changes may not occur in the other sinuses. I will therefore 
describe in general the pathological changes occurring in the entire 
sinus labyrinth, pointing out the changes peculiar to each group of 
cells, in addition to the changes common to them all. In general, it may- 
be said that the pathological changes in the accessory sinuses of the nose 
correspond with the descriptions in general pathology. 

The slighter changes are quite like those in acute suppurative inflam- 
mation affecting other mucous membranes and bone tissue. The 
mucous membrane may present a granular surface, villous and fungoid 
excrescences, granular, cushion-like thickening, etc. In the older cases 
there is thickening from hyperplastic and pyogenic membrane deposits, 
or the membrane may be destroyed in spots by ulceration, exposing 
smooth, bare bone, or the bone may be soft or rough from caries. 
In some cases necrosis and bone sequestra are present, or there is an 
entire loss of the bone. A microscopic examination of sections of 
the mucous membrane sometimes shows a loss of the epithelium and 
glands, which are replaced by connective tissue. Ulcerations of the 
membrane are often surrounded by granulatioii tissue, especially if there 
is bone necrosis. Granulation buds may encroach upon the periosteum, 
and thus unite the bone and mucous membrane. Wliere this happens 
the bone is superficially absorbed and somewhat roughened in conse- 
quence. Osteophytes, or bony scales or plaques, resulting from plastic 
exudation sometimes form on the surface of the bone. 

Cysts of the mucous membrane of the maxillary sinus are present in a 
large number of the cases, according to some observers, while they are 
rather infrequent according to others. Cysts of the middle turbinate 
are usually located in the anterior end, and appear to be dilated ethmoidal 
cells filled with air, mucus, or pus, or an admixture of them. 

I removed one from this region holding a half-dram of stinking pus. 
It should be remembered that the middle turbinated body is a portion of 
the ethmoid bone, and that the pneumatic spaces in it are a part of the 
ethmoidal labyrinth. Cysts are more rarely found in the walls of the 
frontal and sphenoidal cells. 

Polypi have been found in all of the sinuses, although they are more 
common in the antrum and ethmoidal cells. They are much more 
common in the ethmoidal cells than is generally supposed. Their hidden 
location within the small ethmoidal spaces renders their diagnosis rather 
difficult. In the antrum, however, they are more easily diagnosticated, as 
it is quite frequently exposed through the canine fossa. As this sinus 
is quite large, the polypi are easily seen and diagnosticated. They have 
been found in the frontal and sphenoidal smuses, although not so fre- 
quently as in the antrum and ethmoidal cells. The polypi in the eth- 
moidal cells are usually quite small, on accojunt of the limited space within 
tiie cells, whereas, in the antrum they are much larger. In one case, in 
which I exposed the antrum through the canine fossa, the cavity was 
filled with polypi. In empyema of the ethmoidal cells the thin lamina 
papyrnccjp separating the ('('lis from the orbital cavity may bo pcM-foratcd 



l,S4 T/ri-: \osi-: axd accessory sixuses 

or entirely destroyed by tlie siip])iirative proeess. The same is true of 
the eranial ])hite sei)aratin(; the cells from the anterior hemisphere 
of the l)rain. In the latter ease the meninges are exposed to infection, 
and may he the seat of meningitis or epidural abscess. Such an exposure 
of the meninges may exist in cases of latent ethmoidal empyema, with 
no other sym])toms than a slight headache and mental irritability. A 
slight intranasal operation, especially on the middle turbinated body, 
may light uj) the slumbering fires and rapidly lead to a dangerous, or 
even a fatal, meningitis. The cases of meningitis occurring after intra- 
nasal operations are probably to ])e explained in this way, as has been 
shown by (iriinwald in his work on Nasal Suppuration. 

Thrombosis of the longitudinal and cavernous sinuses occasionally 
complicates ethmoidal empyema. Retrobulbar suppuration, or ocular 
cellulitis, is a comparatively infrequent complication of ethmoidal empy- 
ema from narcosis and perforation of the lamina papyrace?e. 

In frontal empyema the floor and posterior wall are most often the 
seat of destructive changes. The floor near the median line is in apposi- 
tion with the anterior ethmoidal cells and nasal septum, hence the cells 
and septum are frequently more or less involved in the carious and necrotic 
retrograde changes. The -anterior ethmoidal cells are always filled with 
pus in frontal empyema. 

Symptomatology. — The Objective Symptoms. — The objective symp- 
toms may be extranasal or intranasal. 

The extranasal symptoms are those changes in the appearance of 
the skin of the face, and of the fundus of the eye as shown by ophthal- 
moscopical examination. In addition to the objective signs the results of 
transillumination and of skiagraphy afford important objective informa- 
tion. 

The intranasal objective signs of sinus disease are those changes in 
the appearance of the outer walls of the nasal chambers and the location 
of the secretion as it drains from the aftected cells. 

The Extranasal Objective Symptoms. — (a) AMien any of the sinuses 
contiguous to the skin of the face are involved (frontal, anterior ethmoidal, 
or antrum) diere may be redness, swelling, and heat of the skin covering 
the afl'ected area. If, for instance, the frontal sinus is acutely inflamed 
there maybe swelling, redness, and heat of the skin in the frontal region; 
likewise in the malar region in antral disease and at the inner angle 
of die orbit in anterior ethmoidal disease. Tenderness upon pressure 
(a subjective symptom) is also present when redness and swelling are 
found. 

(/;) The fniidns of the eye sometimes affords very useful and important 
objective evidence of sinu inflammation. Dr. H. M. Fish has shown 
this comiection more clearly than any other writer, and I am chiefly 
indebted to his writings and to personal conversations with him for 
the facts given in reference to the eye symptoms of sinus inflammations. 
(See Relation of die Eye to Accessory Sinus Disease.) 

(c) 'J'ransillumination of die face affords objective information as to 
the condition of the inaxillarv sinus, and sometimes of the frontal sinus. 



GENERAL CONSIDERATIONS IN REFERENCE TO SINUSES 185 

but none in reference to the other sinuses. In transilhimination of the 
antrum (see Methods of Examination) three points should be noted, 
namely, the red pupillary reflex, the crescent of light corresponding to 
the position of the lower eyelid, and the sense of light in the eye 
when closed. If the red pupillary reflex and the crescent of light are 
absent the antrum is probably affected. Note both sides at once, and 
thus determine which one, if either, is affected. A comparison of the lower 
portion of the field of illumination may be very misleading, as the anterior 
wall of the antrum varies greatly in density, irrespective of the disease 
present. The orbital or upper wall of the antrum is, however, more 
nearly uniform in its density in all cases, and affords a fair opportunity 
for a comparison of the transilluminated light through the two orbital 
plates; that is, when both orbital plates of the antrum are healthy 
the amount of light transmitted through them is about equal; whereas 
when one is thickened it interferes with the transmission of light, hence 
the crescent of light is dimmed or altogether absent. Likewise when 




Birkett's transilluminator for the simultaneous illumination of both frontal sinuses. 



both orbital plates are healthy (antral disease absent) the light transmitted 
into the interior of the eyeball is shown in the red pupillary reflex in each 
eye; whereas if one antrum is involved the pupillary reflex is absent 
upon that side and present in the other. The sense of light (eyes closed) 
is present on the healthy side and absent upon the diseased side in maxil- 
lary diseases. 

Transillumination of the frontal sinuses is an uncertain means of 
diagnosis, as the anterior wall often varies so much in thickness on the 
two sides in the same individual. The hooded lamp should be placed 
under the floor of the frontal sinus at the upper and inner angle of the 
orbit and the two sides compared. Dr. Birkett has devised a double 
lamp (Fig. 125), so that both sides can be illuminated at once to facili- 
tate comparison. If the lamp is not placed well under the supra-orbital 
ridge the skin transmits the light and may thus lead to a false deduction. 
Taken as a whole, ti-iinsilliiiniiiatioii of the tVontal sinuses is not a 
reliable procedure. 



l.SO 



THE XOSE AXD ACCESSORY SIXUSES 



SJciaffraphi/. — Skiagraphy of tlie accessoiy sinuses of the nose should 
Ik- a routine j)ractice when aeeess is had to a competent radiographer. 
Prof, (iustav Kilhan first practised it in diseases of the nasal accessory 
sinuses. Dr. C (t. Coakley has, ])erhaps, used it more extensively than 
anyone else in this field of work. Dr. J. C. Beck and the author 
have also made skiagraphs of about 200 cases. The great difficulty 
has been to find a radiographer who understands the technique well 
enough to j)roduce clear skiagraphic plates. Dr. Caldwell recently 
published his techni((ue, the essentials of which are herewith given. 




Schema showing the proper and improper angles for making a skiagraph of the frontal and 
ethmriidal sinuses, a, the i)roper angle for passing the 3--rays tlirough the head; b, the improper 
angle, as the rays must pass tlirough a great deal of dense bone (rf) to reach the sinus; (f ) an 8 x 10 
inrli photograiiliic i)late against which the forehead sliould rest; e, the table upon which the 
patient lies. Tiie forehead should be placed upon a triangular block with an inclination of 
twent.v-five degrees, as tliis is more comfortable to the patient and renders the line (a) perpen- 
dicular to the table. 

To get a j)late with clearly defined oudines of the sinuses, and with a 
clear definition of die area of Uie sinuses, it is neces.sary to so place the 
a:-ray tube as to avoid the heavy bone of the floor of the cranium, as it 
would interfere with the passage of the rays through the head. The 
.T-ray tube .should be aj)])lied, dierefore, to the back of the head at a point 
above the occiput and floor of the cranium, as .showni by the line a in 
Fig. 12(1. If the tube is apj)lied at b, the ravs would have to traverse 



GENERAL CONSIDERATIONS IN REFERENCE TO SINUSES 187 

through the dense bone of the occiput and the long axis of the plate of 
bone forming the floor of the cranium before it reached the frontal and 
ethmoidal sinuses, thereby interfering with the formation of a clear 
shadow of the dense bone forming the walls of the sinuses and the pro- 
duction of a clear definition of the area of the sinus cavities. If, how- 
ever, the x-TSij tube is applied at a, midway between the occiput and 
the vertex, the rays have an unimpeded course to the frontal and eth- 
moidal sinuses, and the outline and area of the sinuses will be clear and 
well modulated. The delineation of the maxillary sinuses is not so 
clear, as the rays must pass through more bone tissue to reach it. A 
clear skiagraph of this sinus is not so essential, however, as this sinus is 
easily and successfully examined by transillumination with an electric 
lamp in the mouth. 

The advantages derived from skiagraphy of the accessory sinuses are : 

(a) Diagnostic. — If a sinus is healthy its outline on the plate or negative 
is clear and distinct (light) and its area is clear and dark. If the sinus 
is diseased its outline is less clear and distinct and its area is cloudy or 
hazy upon the negative or plate. Prints from the plates are rarely 
satisfactory for diagnostic purposes. 

(6) The dimensions of the frontal sinuses is clearly defined, thus 
affording the surgeon positive information as to the extent of exposure 
necessary before he begins an external operation. A skiagraph through 
the lateral dimensions of the head will show the depth of the frontal sinus, 
thus affording the surgeon additional data as to the probable deformity 
to be expected should the Killian operation be performed. The wider 
and deeper the frontal sinus the greater the deformity following the com- 
plete removal of the anterior bony wall of the sinus. The information 
gained from the two views of the frontal sinus may determine the operator 
to either select or reject a given method of operation. If, for example, 
the skiagraph shows a small, shallow frontal sinus the Killian operation 
might be chosen in preference to other methods, as it is a thorough 
and satisfactory method of operating, and would in such a case be fol- 
lowed by little or no external deformity. If, on the other hand, the plates 
show a large and deep frontal sinus the surgeon might be influenced to 
adopt some other method of operating which would not be attended by 
such marked external deformity. 

(c) In some instances, when the frontal sinus seems to be involved, 
the skiagraph will show a total absence of it, information of no small 
consequence to both the surgeon and the patient. 

The Intranasal Objective Symptoms. — (a) The contour of the outer 
nasal wall sometimes affords information as to the condition of the 
sinuses. In closed empyema of the antrum the inner wall of the antrum 
may be pushed toward the septum. Likewise in empyema of the bulla 
ethmoidalis its median wall may be distended so as to close the hiatus 
semilunaris, or even impinge against the external surface of the middle 
turbinal. 

(//) The texture of the mucous membrane of the nose, especially that 
portion of it covering the middle turbinated borly, is sometimes indicative 



1,9,S THE XnSK AXD ACCKSSORY SIXUSES 

of sinus disease; that is, when the nuieosa of the anterior end of the 
middle turhinal is l)o^'^;v and velvety in texture it usually sif^nifies the 
existence of an ethmoidal sinus inHannnation. 

((•) Polypi are often associated with sinus disease, and are, I believe, 
usually secondary to the sinus infiannnation. 

{d) Pus within the nasal chambers is usually significant of sinus 
emjn-ema. The nasal nnicosa is rarely the focal centre of suppurative 
infiannnation, whereas the sinuses are commonly the focal centre of such 
an inflammation. The presence of pus in the nasal chambers should, 
therefore, excite suspicion of the existence of a sinus inflammation. 
To determine which of the sinuses is involved, see Diagnosis. 

In a general way it may be stated that pus in the middle meatus signi- 
fies an involvement of the frontal, anterior ethmoidal, or the maxillary 
sinus, as these cells drain into the middle meatus. If pus is seen in the 
olfactory' fissure (between the septum and middle turbinal) the posterior 
ethmoi(lal or the sphenoidal cells are involved, as these cells drain into 
the su|)erior meatus (above the middle turbinal). 

The Subjective Symptoms. — The subjective symptoms of sinus inflam- 
ination liave refiM'euce to the sensations of pain and of pressure, the equi- 
lii)rium of the mind, and the impairment of the special senses. 

(a) Pain referable to the region of the sinus involved may or may 
not be present. In active antral or frontal inflammation pain is often 
distinctly referred to the region involved. In the case of the deeper 
sinuses, as the ethmoidal and sphenoidal, the pain is vaguely deep seated 
in the head or referred to the periphery of the head without reference to 
the location of the sinus. For example, sphenoidal inflammation may 
give rise to pain in the occipital or the frontal region. As a matter of 
fact, inflammation in any or all of the sinuses usually causes pain in the 
frontal region. These pains are almost universally callefl headaches by 
the patient. 

(h) Headache is, therefore, one of the commonest and most significant 
signs of sinuitis. Headache has multitudinous causes, and is not, there- 
fore, pathognomonic of inflammatory or other diseased conditions of the 
sinuses. Headache may signify eyestrain, but in this case it is usually 
bilateral, whereas in sinus disease it is more often unilateral, or, if not 
mvilateral, more pronounced on one side, or it begins as a unilateral 
headache and extends to the other side. The headache of sinus origin 
is increased upon st()oj)ing forward and upon a sudden jar of the body. 
It may persist upon closing the eyes upon retiring, or in a darkened 
room ; wlu-reas, if if is of ocular origin it disappears under such conditions. 

The liciKJaciic of ocular origin is greatly increased upon prolonged 
reading and upon attendance at the theatre. The headache caused by 
attendance at the theatre is so characteristic of ocular disturbance that 
it maybe termed "theatre pain." The theatre pain is not characteristic 
of simis disease. 

'Phe j)ains and headache (Uw to disease of the frontal sinus may assume 
the form of sharp, shooting ])ains through the eyes and in the orbital 
region, or they may be dull antl heavy, and nearly constant; or they 



GENERAL CONSIDERATIONS IN REFERENCE TO SINUSES 189 

may consist of a full feeling in the forehead, aggravated by leaning 
forward, which in females is especially well marked during each menstrual 
period (H. M. Fish). Pressure under the floor of the sinus at the inner 
angle of the orbit (Fig. 118) usually elicits pain in these cases. 

(c) Tenderness upon Pressure. — Tenderness and pain upon finger 
pressure may be present in disease of those sinuses contiguous to the 
surface of the face, viz., the frontal, anterior ethmoidal, and the maxil- 
lary sinuses. 

For the examination of the frontal sinus, pressure should be made 
over the anterior wall above the supra-orbital ridge, and under the floor 
of the sinus near the inner angle of the orbit. 

In the examination of the anterior ethmoidal cells, pressure should be 
made at the inner angle of the orbit against the orbital plate of the 
ethmoid. 

In the examination of the antrum of Highmore pressure should be 
made over the canine fossa of the superior maxilla. 

(d) Disturbances of Equilibrium. — Giddiness and vertigo or a momen- 
tary sense of blurred or darkened vision and imminent fainting are 
frequently present in disease of the sinuses. All these symptoms may 
be aggravated or produced by stooping forward. The patient should 
be carefully questioned in regard to these symptoms, as otherwise they 
may be overlooked. When these and the other signs of sinus disease 
are present the diagnosis is fairly well established. 

(e) Disturbances of the Special Senses. — ^The olfactory, visual, and 
auditory senses are frequently disturbed or altogether lost in sinuitis. 

The olfactory sense may be perverted (parosmia), the patient appar- 
ently perceiving odors that are not in evidence to normal noses. A 
more common symptom is the loss of olfaction (anosmia). This is 
accounted for by the blocking of the olfactory fissure by the swollen 
tissues in the region of the middle turbinal, and by the presence of polypi 
and a deviation of the septum in this region. The ventilation of the 
superior meatus of the nose is thereby prevented, hence the loss of the 
sense of smell. In some cases the loss of the sense of smell may be due 
to the degeneration of the terminal filaments of the olfactory nerve, 
although in most cases coming under my observation the sense of smell 
is regained after opening the olfactory fissure either by reducing the 
swollen membrane or resorting to some surgical procedures, as the 
removal of polypi or a portion of the middle turbinal. 

The ocular fiuiction may be disturbed or altogether lost in the course 
of sinus disease. The disturbance may be due to either arterial or 
venous congestion, and to toxins, or to thrombosis of the veins intercom- 
municating between the sinuses and the eye. The morbid process in 
the eye may take the form of a papillitis, neuroretinitis, retrobulbar dis- 
ease, keratitis, errors of refraction or of accommodation, photophobia, 
epiphora choroiditis, iridocyclitis, marginal blepharitis, conjunctival in- 
jection, or restricted field f)r loss of vision. 

The Relation of the Eye to Sinus Diseases. — The intimate relation 
between the veins of the nose and accessory sinuses and of the eye 



lol) 



THE XOSK AXD ACCESSOEY SINUSES 



(Fig. 127), as pointed out by Dr. H. M. Fish and others, shows how rea- 
sonable is the assumption that many of the ocular lesions heretofore 
attributed to auto-intoxication from the intestines, gonorrhea, syphilis, 
and rheumatism, may in many instances be due to an extension of the 
disease from the sinuses to the ocular apparatus via the veins and 
lymphatics. Dr. Fish says: "The ocular symptoms resulting from an 
affection of the accessory sinuses of the nose have attracted a great deal 
of attention during the past few years, and various theories have been 
announced to explain their pathogenesis. According to Ziem, they 
are manifestations of a passive orbital hyperemia from a faulty oxygena- 
tion of the blood, resulting from a hindered nasal respiration, a nasal 
stenosis from edema, polyj)i, purulent secretions, etc. As this hypothesis 
fails to account for a circulatory disturbance limited to the ocular region, 

as well as the instances in which there 
I'ic. 127 is no hindered nasal respiration, the 

nostril presenting a practically normal 
appearance, as it does in some cases, 
the writer has modified the above 
theory and considers the stasis in 
the peri-orbital circulation to be the 
result of a vasodilatation resulting 
from an irritation of the sympathetic 
by the secretion pent up in a closed 
sinus. This theory is based on Gur- 
witch's demonstration, that the vaso- 
supra-orbitalia, frontalia, ethmoid- 
alia, and ophthalmofacialia carry 
the greater portion of the venous 
blood from the nostril and its sinuses 
into the ophthalmic vein, and the 
fact, as shown by Ziickerkandl, that 
the upper walls of the various cavities 
situated at the base of the brain are 
pierced by minute openings, through 
which the lymph and bloodvessels pass, thus affording a direct communi- 
cation between the circulation in these cavities and to the convolutions 
of the brain. An intracranial circulatory disturbance results m cerebral 
symptoms, as vertigo (one of the early and most constant phenomena 
of sinuitis), epileptoid attacks, or unconsciousness (Lichtwitz, Engle- 
mann, Mayer, and the writer), or it may produce meningitis or abscess 
of the brain. A stasis appearing in the orbital circulation may cause an 
edema of the lids, or an exudate behind the globe with a resultant 
])rotrnsion, or it may show itself in any of the eye tissues. If it appears 
in the cornea, for instance, there may be an elevation of the epithelium, 
abrasion, infection, and corneal abscess, with perforation, Avhich may 
necessitate a subsequent emicleation of the eyeball. Should a severe 
intra-ocular involvement take place, and later the fellow eye show inflam- 
matory symptoms, resulting from a sinuitis of the corresponding side, 




Schema showing the venous connections 
of tlie ethmoidal cells with the eyeball. 
aaaa, anterior and posterior ethmoidal 
cells; b, eyeball; c, the superior ophthalmic 
vein; d, the posterior ethmoidal vein; e, the 
anterior ethmoidal vein. 



GENERAL CONSIDERATIONS IN REFERENCE TO SINUSES 191 

the condition could well be mistaken for one of sympathetic ophthalmia. 
Such an instance with enucleation, the only one in the literature, has been 
reported by Ziem." 

It has been claimed by some writers that partial or complete blindness 
may arise as the result of pressure on the optic nerve in closed empyema 
of the sphenoidal sinus. It is quite probable, however, that most cases 
of blindness occurring in the course of sinuitis are due to venous stasis 
and thrombosis rather than to direct pressure upon the optic nerve. 
In the case reported by Dr. Fish, in which the eye symptoms were 
prominent, the frontal sinus was involved, although eye lesions may 
arise in the course of an inflammation in any of the sinuses. 

In addition to the foregoing eye lesions, the patient may complain 
of pains shooting through the eyes, and other signs of inflammation of 
the visual apparatus. 

The auditory functions may be more or less disturbed by sinus disease. 
The discharge from the sinuses into the epipharynx may cause infection 
of the mucous membrane of the Eustachian tube and middle ear. 
Sinuitis may indirectly be the cause of middle-ear catarrh or of sup- 
purative otitis media and mastoiditis. In addition to the foregoing ear 
complications, there is another symptom I do not happen to have seen 
mentioned in the literature, namely, a momentary roaring accompanied 
by a fulness in the ears and dulness of hearing. These phenomena are 
especially liable to occur on stooping forward. 

The Principles of Treatment. — The cure of sinus inflammation depends 
upon two propositions, namely, (a) the establishment of free drainage 
and ventilation, and (6) the removal of the morbid material. 

In those cases in which the interference with drainage and ventilation is 
due to a simple hyperemia of the mucous membrane the local application 
of cocaine, antipyrine, or adrenalin may be quite sufficient to establish 
a cure. In such subjects the morbid material is the secretion, hence 
drainage removes it. On the other hand, in those cases in which there 
is marked obstruction due to a deviation of the septum or to hyperplasia 
of the middle turbinal it is often necessary to resort to surgical measures 
in order to obtain relief. Furthermore, in those cases in which the sinus 
is filled with granulation tissue and the bony walls are necrosed the 
establishment of drainage even by surgical means may not effect a cure; 
the morbid material (granulations and necrotic bone) must also be re- 
moved. 

The Indications. — An appreciation of these fundamental principles 
enables the surgeon to decide upon the method of treatment in each case. 
In the following discussion of the treatment the foregoing principles will 
be constantly referred to with a view of enabling the student and prac- 
titioner to elect the proper mode of treatment in the cases coming imder 
his observation. Before entering upon a detailed description of the 
various modes of treatment a general discussion of the vaiying conditions 
to be met will be given. 

Acute catarrhal sinuitis is usually an extension of a similar inflannna- 
tion of the nasal mucosa to the sinus, in the course of a coryza or cold 



|(,2 '/•///■; vo.s/-; .t.\7) .i('C7;.s',sYj/i')- sixuses 

ill the lic;i(l. 'I1ic inufous iiK'inhraiie of the nose and sinuses is liyperemic 
and swollen. The cell openings may be closed from swelling of the 
nuKoiis nuiiil)rane around them. TJie obvious indication is to relieve 
the swelling by the local a])})licati()n of certain drugs, surgical intervention 
being rarely justifiable. 

Acute su"j)j)urative sinuitis occurring in the course of coryza is charac- 
terized by hyj)eremia and swelling of the mucous membrane of the nose 
and sinuses, and the indications are to reduce the swelling by local medi- 
cinal aj)])lications, as in the acute catarrhal variety. 

Chronic c-atarrhal sinuitis due to pressure in the middle turbinal 
region demands the removal of the tissue causing the pressure. If the 
nnicous membrane is chronically swollen, temporary relief may come 
from the aj)j)licati()n of antiphlogistic drugs, as adrenalin. If the secre- 
tions have dried and blocked the cell openings, probing may afford 
temporary relief. In most cases the middle turbinal is enlarged from 
hyperplasia or from cystic formation, and blocks the infundibulum. 
In some cases, therefore, it is necessary to either straighten the septum 
or remove a portion of the middle turbinal in order to give permanent 
relief from the symptoms. The bulla ethmoidalis may also block the 
infundibulum and prevent drainage and ventilation of the sinuses in 
Series I. 

Chronic suppin-ative sinuitis, with obstructive lesions, demands the 
removal of the obstructive lesions, whether they be of septal, turbinal, 
or of other origin. As there is simple obstruction and no morbid material 
other than pus, the removal of the obstructive lesions permits of drainage 
and of the removal of the morl)id material (pus). The foregoing state- 
ment does not apply, however, to all cases, as the drainage of pus from 
the cells is not altogether dependent upon free cell openings, as in most 
of the cells the opening is near their upper limit. The ciliated columnar 
epithelium lining the cells, though limited in distribution, carries the 
secretions up to the cell openings, where it is discharged into the nasal 
cavity. If, therefore, the ciliae are destroyed by the inflammatory process, 
the removal of the obstructive lesions does not necessarily establish free 
drainage. In such cases it may be necessary to institute operative 
])rocedures to open the cells at their most dependent portion, or to ex- 
enterate them in dieir entirety (ethmoidal). In some cases the mucous 
membrane and the ciliated epithelium can be restored to their normal 
integrity and functional activity by lavage, or by negative air pressure, as 
recommended by liier. 

Chronic sup])urative sinuitis wiUiout ()l)structive lesions of the septum 
(»!• Ilic middle turbinated body implies a degeneration of the mucous 
m<'nibiane with a loss of the cohunnar ciliated epithelium of the sinuses, 
at least in certain areas. The treatment shoidd, therefore, either be 
directed toward the regeneration of the mucous membrane by negative 
pressure, and die resultant hyj)eremia and increased nutrition, or by 
o|)ening (lie cells and establishing fre(> drainage by some operative pro- 
(•('(liire. 

Chronic suppurative shmitis with granulations, polypi, or bone necrosis 



GENERAL CONSIDERATIONS IN REFERENCE TO SINUSES 193 

is only amenable to surgical treatment. No treatment other than this 
will establish drainage and ventilation and remove the morbid material. 

Treatment. — The principles of treatment having been given, only 
the technique of the treatment will be described in this section. 

Treatment of Acute Catarrhal Sinuitis. — Acute catarrhal sinuitis usually 
involves all the accessory sinuses, and the indications call for the reduc- 
tion of the swelling of the mucous membrane for the purpose of opening 
the ostei of the sinuses. The following technique is usually successful : 

(a) Apply adrenalin, 1 to 2000, on thin pledgets of cotton, to the swollen 
middle and inferior turbinals to reduce the swelling. 

(b) Apply a 4 per cent, solution of cocaine to reduce the swelling and 
to relieve the hypersensitiveness of the mucous membrane. 

(c) Apply a 10 per cent, solution of antipyrine over the same area to 
prolong the ischemic effects of the adrenalin and cocaine. 

(d) Use a 0.5 per cent, solution of menthol or other bland aromatic 
oily solution with a nebulizer every two or three hours. 

The solutions of adrenalin, cocaine, and antipyrine should be used as 
often as the nasal chambers become stuffy, or the headache and sense 
of pressure returns. 

In addition to the foregoing local remedies the internal administration 
of the usual remedies given in acute coryza may be given, but they are 
only of value in the early stage. (See Treatment of Coryza.) 

Heat applied with a 500 candle-power lamp (Fig. 19) over the face 
sometimes affords immediate relief. The lamp should be passed back 
and forth before the closed eyes, at a distance of from twelve to eighteen 
inches, for twenty to thirty minutes. The good effects are due to the in- 
creased hyperemia and leukocytosis, and to the improvement of the nutri- 
tional processes. While germicidal properties are claimed for the light of 
this lamp, the effects may be explained by the increased leukocytosis and 
nutrition of the tissues. I have treated old chronic cases with the light 
in which the purulent discharge and pain disappeared, but returned after 
a few weeks. Whether persistent use of the light will cure these cases 
I am not prepared to state. 

Treatment of Chronic Catarrhal Sinuitis. — This is more difficult to suc- 
cessfully treat on account of its chronicity, which of itself may imply that 
anatomical barriers existed during the acute stage to prevent resolution. 
These barriers, if present, must be overcome before a cure can be 
permanently established. The anatomical barriers to resolution may 
consist of hypertrophic or hyperplastic changes in the mucous membrane 
of the nose, especially in the region of the cell openings and the olfactory 
fissure, or they may be due to cystic formations in the middle turbinal 
or to deviations of the upper portion of the nasal septum. 

The swelling of the mucosa may be somewhat reduced by the local 
applications of adrenalin, cocaine, and antipyrine. In addition to this, 
the hypertrophic or hyperplastic rhinitis should be treated after the 
manner described under these diseases. 

If these measui-es fail, more radical surgical procedures, such as are 
used in obstinate cases of suppurative sinuitis, may become necessary. 
13 



104 THE SO SIC A.\'D ACCESSORY SIX USES 

rrul)iii<; the frontonasal canal sometimes affords relief, although the 
removal of the anterior end of the middle tiirbinal and the curettement 
of the ethmoidal cells may he necessary. 

Treatment of Chronic Suppurative Sinuitis. — In the simpler form of 
sinuitis, that is, where there are no granulations and carious bone, the 
lavage of the affected sinus with antiseptic, alkaline, or stimulating solu- 
tions is sometimes followed by a cure. The lavage of the frontal sinus 
may be performed through the frontonasal canal, except in those cases 
in which it is absolutely closed by an enlarged bulla or by an enlarged 
middle turbinated body. 

Lavage of the Frontal Sinus. — An understanding of certain anatomical 
peculiarities of the region of the infundibulum and the frontonasal 
canal will materially aid in the lavage of the sinuses. The hiatus semi- 
lunaris, the infundibulum, and the frontonasal canal will be clearly 
defined, as much confusion appears in the literature concerning them. 
The terms are often used as s}iionymous, whereas they are distinct 
anatomical entities. 

The hiatus semilunaris is a slit-like crescen tic-shaped opening in the 
outer wall of the nose. It is the opening of the infimdibulum into 
the middle meatus of the nose. Its inner lip is the upper margin of the 
uncinate process of the ethmoid bone. 

The infundibulum is a deep, narrow groove or gutter in the outer wall 
of the nose (Fig. 129/), the inner wall of which is the uncinate process. 
The frontonasal canal drains into the infundibulum in about one-half 
of the subjects, whereas in the remainder it drains a little anterior to 
it directly into the middle meatus (Turner). 

The frontonasal canal is a closed tubular duct extending upward and 
forward from the middle meatus or the infundibulum, as the case may be, 
to the frontal sinus. Its opening into the floor of the frontal sinus is 
known as the ostium frontale. 

IIa\ing defined the parts concerned in probing or irrigating the frontal 
sinus, certain anatomical peculiarities which influence the procedure 
will be given brief notice. 

The hiatus semilunaris is the key to the probing, as it is the opening 
into the infundibulum, which must be entered to reach the frontonasal 
canal in about one-half of the cases. The bulla ethmoidalis is situated 
just above the hiatus, and when large it encroaches upon the slit-like 
opening and partially or completely closes it. Occasionally there is an 
accessory cell in the uncinate process, which also obstructs the hiatus. 
In other cases the middle turbinal closely hugs the outer wall of the 
nose and blocks the hiatus (Sluder). When either of these anatomical 
peculiarities is present the introduction of the probe or the cannula is 
rendered difficult or impossible. If the frontonasal canal opens in front 
of the infundibulum the probe or cannula may be passed into it even 
though the hiatus is closed. 

Another difficulty sometimes encountered in probing is, that the probe 
may enter the ostium of one of the anterior ethmoidal cells instead of 
the frontal sinus. Some of the anterior cells may open into the infun- 



GENERAL CONSIDERATIONS IN REFERENCE TO SINUSES I95 

dibiilum on its outer wall, wliile'others open into the frontonasal canal. 
The anterior cells are usually located external to the infundibulum and 
the frontonasal canal and their ostei open into the infundibulum and 
frontonasal canal, through the outer wall. In probing, therefore, the 
point of the probe should be kept against the inner or mesial wall of the 
frontonasal canal in order to avoid the ostei on its outer wall. 

Probing is generally more difficult in those subjects in which the 
frontonasal canal empties into the infundibulum than when it empties 
directly into the middle meatus. In the former case the canal is often 
tortuous and narrow, while in the latter it is usually straighter and of larger 
caliber. 

The middle turbinal is sometimes so close to the hiatus, especially 
when the turbinal contains an accessory cell, that it is difficult to enter 
it with a probe or cannula. In this event the removal of the anterior 
third of the turbinal overcomes the difficulty. 

The Technique of Probing the Frontal Nasal Canal. — First cocainize 
the parts. Then introduce a fine silver probe (Fig. 128), bent at its 
distal end to an angle of about 135 degrees, between the anterior third 
of the middle^ turbinal and the outer wall of the nose. Keep the tip of 



Holmes' malleable frontal sinus probe. 




the probe against the outer surface of the turbinal and pass it forward 
and upward through the hiatus into the infundibulum, where it readily 
enters the frontonasal canal even to the osteum frontale (Fig. 129). 
After engaging in the middle meatus it should be passed into the infun- 
dibulum and canal for about 6 to S cm. to reach the frontal sinus. 

The irrigation of the frontal sinus is accomplished through a silver 
cannula, which is introduced in the same manner as described for 
the introduction of the probe. The syringe is attached to the cannula 
(Fig. 130) and the sinus gently irrigated with warm normal salt or boric 
acid solution. 

Lavage of the splienoidal sinus is possible when the middle tm-binal, 
or a deflection of the septinn, does not prevent the introduction of the 
sphenoidal cannula into its opening. When such an obstruction is present 
it may become necessary to first remove it by some surgical procedure 
before the irrigations can be practised. Personally, I am in the habit of 
using a silver Eustachian catheter in place of a sphenoidal cannula, and 
find the curve used for the inflation of the ear the correct one for irriga- 
tion of the sphenoidal sinus. Myles' cannula (Fig. 130) maybe bent to 
reach any sinus, and is smaller than the Eustachian catheter. 



19(j 



rilE XOSK AXD ACCESSURY SIXUSES 



Larof/c of the Maxillary Sinus. — Tlris can rarely be effected tlirougb 
the cell opening on acconnt of its hidden position in the infundibulum, 
and on acconnt of the forward and downward direction of the antral 
opening from the infinuHbuluni to die antrum. The opening into the 



,f^' 




Probing the frontal sinus. Tiie anterior half of the middle turbinated body is removed to 
siiow tlie anatomical landmarks, n n, the probe in the first i)osition beneath the middle turbinal 
and posterior to the bulla ethnioi<lalis; h, the probe in the second position beneath the middle 
turbinal and in front of the bulla ethmoidalis; cc, the probe in the third position introduced 
throuRh tlie frontonasal canal into the frontal sinus; d. the nasal end of the frontonasal canal; 
e, the lip of the uncinate process; f, the inner wall of the infundibulum; g, the osteuni bulla eth- 
moidalis; A. the osreum maxillare; i. an accessory opening into the maxillary sinus. (Drawing 
from a specimen loaned by Dr. Ira Frank.) 

antrum is not directly tlirough the lateral wall of the nose, but it is more 
like a canal extending obliquely downward and forward through the 
thickness of the wall. The canal or opening is furdiermore somewhat 
hidden by the unciform process, or lip, of the hiatus semilunaris. Some 
writers have claimed that they could irrigate the antrum through its 



=<Bm^ 



Myles' >inus cannula. 



normal opening, but a casual study of the anatomical peculiarities of the 
region will convince anyone that it is a physical impossibility, except 
in rare instances. In a certain ninnber of cases there are accessory 
openings into the antrum (f'ig. 129 /), which when present may be utilized 



GENERAL CONSIDERATIONS IN REFERENCE TO SINUSES 197 

for irrigation purposes. Then, too, the lamina membranacea of the naso- 
antral wall may be perforated with the tip of the cannula and irrigation 
performed through it. In view of the foregoing facts it is rarely possible 
to irrigate the antrum through the normal osteum, hence an artificial 
route should be chosen, the most available one being beneath the inferior 
turbinated body, a curved trocar and cannula being used for the purpose. 
The technique is as follows: 

(a) Anesthetize the mucous membrane of the inferior meatus with 
a 5 per cent, solution of cocaine. 

(6) Introduce the trocar and cannula beneath the inferior turbinal 
posterior to the anterior antral wall, and direct it upward and outward, 
a little above the floor of the nose, in order to avoid the thick wall of bone 
at this point (Fig. 123). 

(c) After penetrating the naso-antral wall remove the trocar, leaving 
the cannula in position. 

(d) Attach the rubber hose of the syringe to the cannula and irrigate 
with normal salt or other solution chosen for the purpose. 

(e) By cocainizing the area daily the irrigations may he continued 
through the artificial opening indefinitely. 

Lavage of the Antrum through the Alveolar Process. — This may be 
done after having performed the Cooper operation, so named after Sir 
Astley Cooper, who introduced it to the profession. 

The technique is as follows: (a) Select a place where a tooth has 
been extracted, or if a tooth is decayed beyond repair, extract it for 
the purpose, and drill a canal into the floor of the sinus. This is Cooper's 
operation. 

(b) Through this opening a cannula is introduced and the antrum 
irrigated with normal salt or any solution desired. 

(c) The canal thus made should be kept open by wearing a hard or 
soft rubber or gold tube made for the purpose. The tube should be 
flanged on the alveolar end to prevent it slipping upward into the 
antrum 

(d) A plug should be introduced into the tube to prevent food entering 
the antrum. 

Lavage through a canal external to the teeth. 

(a) Cocainize the gums. 

(b) Drill a canal through the upper and external part of the alveolar 
process at a point between the first and second bicuspids, avoiding the 
roots of the teeth. 

(c) Proceed thereafter as in the Cooper operation. 

This procedure is generally chosen rather than the Cooper operation, 
as the teeth are usually present, and, even if diseased, are amenable 
to dental treatment. Neither method is recommended. 

Lavage of the Ethmoidal Cells.- — ^This is often impossible except 
in the case of the anterior cells which drain into the frontonasal canal. 
The bulla ethraoidalis, one of the anterior cells, does not drain into 
the frontonasal canal, but drains directly into the middle meatus, and 
its ostium is situated at its upper median wall. 



lOS 



TIIK XOSH AXD ACCESSORY SIXUSES 



TJie tecliiii(|iie for tlie lavage of the anterior cells opening into the 
frontonasal canal is the same as for the frontal sinus; indeed, both sets of 
cells are often irrigated at the same time. Their ostei are bathed with 
the irrigating iluid and the accunndated pus in the canal is removed, 
thus facilitating the drainage of the cells. 



.r^ 



-^CQ 



-FTT 



/-^^ 



Andrews' sphenoidal luolie r:innu 

Andrews' Lavacje of the Sphenoidal Sinus. — A. H. Andrews has 
devised a curved cannula (Fig. 131), which can be introduced into the 
sphenoidal sinus without the preliminary removal of the middle turbin- 
ated body. This is a decided advantage, as it renders the treatment 
of empyema of these sinuses a very simple procedure. Should granu- 
lations be abundant it may be necessary to first remove the middle 
turbinal and then the anterior wall of the sphenoidel sinus and curette 
its anterior. 




Iirinati 



lienoidal sinus widi Andrews' curved cannula. 



The s|)ecial curve of Andrews' cannula enables the operator to iusin- 
niitc it throiigh llie olfactory fissure into the spheno-ethmoid fossa, and 



GENERAL CONSIDERATIONS IN REFERENCE TO SINUSES 199 

by rotating it to engage the tip in the ostium sphenoidale (Fig. 132). 
When thus introduced, have the patient lean forward and open his 
mouth, then attach the hose of the syringe to the cannula and irri- 
gate the sinus. With the head inclined forward and the mouth open 
the fluid will not enter the Eustachian tube. 

General Remarks Concerning Lavage or Irrigation of the Sinuses. — 
Lavage of the sinuses in suppurative inflammations is, upon the whole, 
an unsatisfactory therapeutic measure. Formerly it was in vogue 
with dentists and surgeons for the treatment of antral empyema. 
Many cases were treated daily, for weeks and months, and some 
were cured, or apparently cured, while others continued to suppurate 
uninterruptedly. All the cases were treated alike except as to the solution 
used in individual cases. 

If lavage is useful at all it is in the simple suppurative cases uncom- 
plicated by granulations and necrosis. The removal of the purulent 
secretions gives the ciliated epithelium a chance to regenerate. It should 
also be borne in mind that the mucous membrane does not tolerate 
lavage indefinitely, as it is not accustomed to the presence of a large 
quantity of aqueous solution, hence irrigation is a doubtful procedure. 
If after a few days or weeks' trial the case does not greatly improve 
the irrigation should be discontinued and some other method of treat- 
ment, probably surgical in character, instituted. 

Treatment by Negative Air Pressure. — Bier has demonstrated the 
therapeutic value of this method of treatment in inflammations. Sonder- 
mann, Brawley, and others have also reported favorably upon the use 
of negative pressure by means of an exhaust pump. The rationale of 
this method of treatment consists chiefly in the increased hyperemia of 
the mucous membrane lining the cells. The local nutrition is thereby 
improved, the cell resistance and leukocytosis increased, and the infective 
process checked. That such changes do take place in some cases 
thus treated is probably true. It is not claimed that all cases are amen- 
able to this treatment. Let it be well understood, therefore, that negative 
air pressure should be used only as a tentative measure, and if a cure does 
not follow within a few weeks it should be abandoned and some other 
treatment substituted for it. 

Technique. — (a) The apparatus necessary for producing negative 
pressure in the sinuses consists of either a hand pump or other device 
for exhausting the air in the nasal chambers. Brawley's apparatus is 
operated by attaching it to a faucet of the washbasin, the negative 
pressure being regulated by the amount of water turned on. 

(b) Insert the nasal tips into the nostrils and bring the soft palate 
into apposition with the pharyngeal wall by swallowing. With practice 
the patient soon learns to maintain this condition for several minutes. 

(c) While the air is thus exhausted the pus is drawn from the sinus 
into the rubber tubing, from whence it flows into the reservoir bottle. 
In this way several drains or ounces of pus may be removed in the course 
of a half-hour. 

(d) Daily seances should be maintained until improvement appears, 



200 THE NOSE AND ACCESSORY SINUSES 

or until the surgeon is convinced that this method of treatment is inade- 
quate for the case. 

Drs. Dabney and Pynchon have devised exhaust apparatus having 
the appearance of a spray tube (Fig. 18), which is operated with a 
compressed-air tank. They are ingenious and practical instruments. 

With either apparatus the patient is instructed to swallow, thus clos- 
ing off the pharynx from the epipharynx and nose. The suction, after 
a little practice on the j)art of the patient, maintains the palate muscles 
in this position for an indefinite period of time. The patient during this 
process breathes through the mouth. 



CHAPTEH XI. 

THE SURGERY OF THE ACCESSORY SINUSES. 

THE KEY TO SINUS DISEASE, OR THE "VICIOUS CIRCLE" OF 
THE NOSE. 

In the chapter on the Etiology of the Inflammatory Diseases of the 
Nose and Accessory Sinuses it was shown that the chief predisposing 
cause of sinus inflammation is an obstruction in the region of the middle 
turbinated body and the hiatus semilunaris. The obstructive lesion 
may be a deflection of the nasal septum, an enlarged or cystic middle 
turbinal, an enlarged bulla ethmoidalis, or cells in the uncinate process 
(the median wall of the infundibulum) . (Figs. 1 33 to 1 39. ) As the frontal, 
anterior ethmoidal, and the maxillary sinuses drain into the infundibulum 
(exceptions noted, p. 167), an obstruction in this region may occlude 
either or all of these sinuses. When either of them is the seat of in- 
flammation it is always advisable to make a careful examination of this 
region. The area to be thus examined is shown in Fig. 140 within the 
circle. These structures may be designated the "key" to sinus inflamma- 
tion, or the "vicious circle" of the nose. Being the key to the etiology 
of sinus infection, it is also the key to the treatment of the infection; that 
is, if the obstruction predisposing the sinuses to infection is located 
within the area of the circle, it is obvious that if this area is freed from 
obstruction the chief etological factor will have been removed, and 
having been removed, the infectious process tends to subside. 

The following principle may, therefore, be given as a working basis 
in the treatment of inflammatory diseases of the sinuses composing 
Series I. (See Chapter IX.) 

Remove the obstruction within the "key," or vicious circle," before 
attempting more radical measures. 

By so doing the drainage of the sinuses may be established and a cure 
result. This principle is of so nearly universal application that it forms 
a good working basis, and, if observed, will prove of inestimable value, 
as it will often obviate the necessity of resorting to the more radical 
operations in the treatment of these sinuses. Should the recommenda- 
tions given above fail to relieve the disease, the more radical operative 
procedures may be performed in due time. 

Various writers have made the clinical observation that meningitis 
is more liable to follow the radical external operation if an intranasal 
operation is performed a few days prior to the radical operation. The 
following deduction is, therefore, obvious: 




Fig. 133. — A high deviation of the septum, causing closure of the infundibulum. a, high devia- 
tion of the septum; h, inner wall of the bulla ethmoidalis; c, middle turbinal crowded again.st the 
outer wall of the nose, and blocking the drainage of the infundibulum. 

Fig. 134. — Cross-section through the nose, a, hyperplasia of the middle turbinated body, which 
crowds upon the uncinate process (c) and closes the infundibulum. 



Fig. 135 



Fig. 136 





e mucous membrane of the middle turbinal, blocking the infundibulum. 
inal; b, bulla ethmoidalis; c, uncinate process or inner wall of the 



Fig. 135. — Edema of tl 
a, edematous middle twil 
infundibulum. 

Fig. 13G. — A large cyst of the middle turbinated body, occluding the infundibulum. a, cystic 
middle imbinal; h, the inner wall of the bulla ethmoidalis; c, the uncinate process or inner wall 
of the infundibulum or gutter. 





Fig. 137. — Enlargement of the bulla ethmoidalis, blocking the infundibulum. a, the inner and 
distended wall of the bulla ethmoidalis, crowding inward and downward against the uncinate pro- 
cess and blocking the infundibulum; b, the uncinate process; c, the middle turbinal, which, on 
account of the bulging bulla, appears to be the cause of the blockage. 

Fig. 138. — The middle turbinated body (a) clinging to the outer wall of the nose and blocking 
the infundibulum; b, inner wall of the bulla ethmoidalis; c, uncinate process or inner wall of the 
infundibulum. 




Cyst of flip uncinate' rirocpss (b) blocking the infundibulum; a, linlla dhnmiilalis; r, middio 
turbinated body. 



204 



THE NOSE A.XD ACCESSORY SIXUSES 



Never do a prrliminari/ intranasal opcralion a few daj/s before a radical 
sinus operation. 

Several days or a few weeks should elapse between a preliminary 
intranasal operation and a radical sinus operation, to allow a wall of 
})rotecting granulation tissue to be formed. An additional reason for 
delaying the radical operation is, to allow sufficient time to elapse to 
determine whether the intranasal operation is adequate to cure the dis- 
ease. I have seen serious cases get well most imexpectedly under such 




Tlie "vicious circle" of the nose, the area of which is often responsible for infection and inflam- 
mation of tlie frontal anterior ethmoidal and the maxillary sinus, b, the spheno-ethmoidal 
fossa; c, the superior turbinated body; d, posterior ethmoidal cells; /, anterior ethmoidal cells 
draining into the frontonasal canal; g, frontal sinus; h, the ostium of the bulla ethmoidalis; 
i, hiatus semilunaris; k, the uncinate process or outer wall of the infundibulum or gutter on the 
outer wall of the nose into which the frontal, anterior ethmoidal, and maxillary sinuses usually 
drain. The high light below and anterior to j and A; indicates the inferior boundary of the infun- 
dibulum or gutter into which the sinuses drain. The middle turbinated body is removed to exhibit 
the anatomical details beneath it. 

treatment. I wish to state most emphatically, however, that, having 
found the simple intranasal operation ineffective, the surgeon should 
unhesitatingly })erform a more radical operation. My plea is for 
rationalism rather than against radicalism. I do not plead for so-called 
"conservation," a term which has been used to justify timidity and 
surgical inefficiency. The true conservative is a rationalist who dares 
to refrain from radical procedures, and yet who dares to undertake them 
when indicated. 



THE SURGERY OF THE FRONTAL SINUS. 



The surgical treatment of frontal sinuitis may be divided into (a) 
intranasal, and (6) extranasal operations. 



THE SURGERY OF THE FRONTAL SINUS 



205 



The intranasal operations consist in the removal of obstructions within 
the "key," or "vicious circle," and in the more extensive operation of 
Halle. 

Intranasal Operations for Frontal, Anterior, Ethmoidal, and 
Maxillary Sinuitis. — Operations within the "Vicious Circle." — 
(a) Local cocaine anesthesia should generally be depended upon, though 
general anesthesia is preferable in certain cases. 

(6) Remove the middle turbinated body or such part of it as obstructs 
the area within the circle shown in Fig. 140. Even though the middle 
turbinal does not actually obstruct the hiatus and infundibulum, it 
may be necessary to remove a portion of it to expose the field to surgical 
intervention. Physiologically there is little objection to the removal of 




Fig. 141. — Showing a large bulla ethmoidalis (a) encroaching upon the hiatus semilunaris; (&) 
the hiatus semilunaris. The middle turbinal has been removed. (Dr. W. A. Fisher's specirnen.) 

Fig. 142. — The anterior cell is the frontal sinus; the posterior one is one of the anterior eth- 
moidal cells extending half-way across the orbital cavity, and is inaccessible to operation except 
by bent curettes through the nasal chambers. The author recently operated three such cases. 
(Dr. W. A. Fisher's specimen.) 



this structure. The olfactory nerve is not distributed to its mucous 
membrane, and the swell bodies are rudimentary. The method of 
removal should be selected with reference to the anatomical conforma- 
tion present and the individual preference of the surgeon. The author's 
turbinal knife (Fig. 172) is usually well adapted to the purpose. (The 
various methods of performing turbinectomy and turbinotomy are 
described on pages 152 to 155 and 2.31 and 232.) 

(c) Remove all of the anterior ethmoidal cells that can be reached 
with the curette, Griinwald forceps, or other instruments. Owing to 
the wide variation in the distribution of the anterior ethmoidal cells, 
the area of curettement varies in each case. In some subjects all the 
cells are not accessible to the curette. Occasionally one of the cells 
extends over the orbital roof posterior to the frontal sinus, as shown 



200 



THE XOSE AXD ACCESSORY SIXUSES 



in Fi<ij. 142. In other cases a cell encroaches upon the floor of the 
frontal sums and forms the so-called bulla frontalis, as shown in Fig. 143. 
The dense bone of the frontonasal spine of the superior maxillary bone 
often shields some of the most anterior of the cells from the curette. 
For these reasons the total exenteration of the anterior ethmoidal cells 
with the curette is not always possible by the intranasal route. As a 
consequence the frontonasal canal and the infundibulum cannot always 
be cleared of obstructive lesions. Drainage of the frontal sinus is not, 
therefore, always possible by this method of operating. 

Should the subsequent course of the frontal sinuitis prove the inade- 
quacy of the operation, either the Halle or one of the external operations 
is recouuuended. After an experience in more than two hundred cases 
operated via the "vicious circle" of the nose, I am convinced that but 
few casesW frontal and cthmoi(hd sinuitis require more radial surgical 




Sliowiiig tlie nasal sinuses of the right side of the head. Tlie na.so-antral wall, inferior turhi- 
nal and the middle turbinal are removed. One of the anterior ethmoidal cells (a) projects into 
the floor of the frontal sinus and forms the so-called bulla frontalis. (Author's specimen.) 



interference. In only 'A per cent, of the cases was it necessary to per- 
form an external operation. As the infundibulum is the outlet of the 
drainage system of the sinuses comprised in Series I, and as the 
anatomical deformities of the septum, middle turbinal, and bulla eth- 
nioidalis often obstruct the drainage and ventilation of the infundibulum, 
it is a rational conclusion that, if the obstructive anatomical lesion is 
removed, drainage will be restored and the infection and inflammation 
cured. 

Hemorrhage is the most troublesome complication attending this 
operation. The })arts are chiefly supplied by the anterior and posterior 
ethmoidal and a branch of the sphenopalatine artery (Fig. 3). They 
are of considerable size and may bleed freely, though in my experience 
they rarely do so. The hemorrhage, though not profuse, usually con- 
tinues for about twenty-four hours. A firm tampon of gauze in the 



HALLE'S FRONTAL SINUS OPERATION 207 

upper portion of the nasal cavity readily checks it. Fortunately it is rarely 
necessary to introduce a tampon for this purpose. The presence of the 
tampon may prove as serious as the operation, as it may fracture the 
orbital plate and expose the orbital contents to infection. A tampon 
should not, therefore, be introduced except in case of severe hemorrhage. 
Drainage is of more importance than the control of a slight hemorrhage. 
Place the patient in a hospital if possible, as the hemorrhage can be kept 
under better control than it can if the patient is at home. 

After-treatment. — Instruct the patient to introduce a pledget of cotton 
in the vestibule of the nose and to remove and renew it as often as it 
becomes soiled with blood and secretions. This protects the denuded sur- 
faces from being irritated by the inspiratory current of air and prevents 
the blood trickling over the upper lip. A dusting powder of bismuth- 
iodine should be insufflated once or twice daily. Healing usually 
occurs in about fourteen days, and if the exenteration is complete 
the space in the ethmoid region should be free and roomy. For a few 
days after the operation small pledgets of cotton, saturated with a 10 per 
cent, glycerin solution of ichthyol, should be introduced every four 
hours into the attic of the nose to promote osmosis and asepsis of the 
surgical field. 

HALLE'S FRONTAL SINUS OPERATION. 

Max Halle, of Berlin, enters the frontal sinus by the intranasal route 
by means of burrs and a protector to the internal plate of the frontal 
bone. The chief source of danger attending this operation is the injury of 
the internal plate of the frontal bone, thereby openmg an avenue of 
infection to the meninges and brain. The grooved protector is intended 
to prevent the injury of this plate, and it should always be used. 

The anatomical barrier to the removal of the floor of the frontal sinus 
is the backw^ard projection of the spina nasofrontalis of the superior 
maxillary bone, as shown in Fig. 145. This dense, heavy bone was 
regarded as an insurmountable barrier to the floor of the frontal sinus 
by the intranasal route, until Halle recently called attention to this 
method of operating. 

Indications. — The Halle operation is indicated in those cases of frontal 
and anterior ethmoidal sinuitis which have resisted the removal of the 
anatomical obstructive lesions within the "vicious circle" of the nose, 
and in which there are no fulminating symptoms, as meningitis, orbital 
abscess, and external perforation. When these symptoms are present 
an external operation should be performed. 

Technique. — (a) Induce local anesthesia with cocaine. 

(h) Introduce a probe into the frontal nasal canal for a distance of 
2! to 3 cm. after it enters the infundibulum or hiatus semilunaris, as 
when it is passed upward and forward this distance it has entered the 
frontal sinus. 

(c) Introduce the protector alongside the probe for the same distance. 

(d) Next engage the pointed drill (F'igs. 144 and 145) against the 



208 



rilE XOSE AND ACCESSORY SIXUSES 



uiultT and j)o.stcnor border of the spina nasofron talis, just in front of the 
jjrotector. Direct the drill forward and upward and remove enough of 
the bone to allow the blunt-pointed drill (Fig. 144) to be introduced. 
The sharp-pointed drill should only be used to make an opening large 
enough to permit the introduction of the blunt-pointed one, as to use 
it further might lead to injury of the internal plate of the frontal bone. 
The blunt drill will not do this. 

(c) With the blunt drill remove enough of the bone to permit the 
introduction of the pear-shaped drill (Fig. 146), the thickened portion of 
which is rounded and polished. Halle says: "With this instrument no 
dangerous injuries can be caused, provided the least care is taken. The 




Halle's frontal sinus buns and handle. 



entire floor can be drilled away with it, and so large a part of the external 
])late <)f the frontal bone in a do\\iiward direction that the instrument 
can be felt from without. It is necessary that the assistant take the pre- 
caution to push his finger well into the orbit, so that he can control the 
head of the instrument (drill) and prevent it going too far to the front or 
the sides." 

The mucous membrane of the frontal sinus may thus be exposed to 
ocular inspection and treatment through the nose if the bone is thor- 
oughly removed, as shown in Fig. 147. 

(f/) The after-treatment consists in first packing the sinus with iodo- 
form gauze, and the subsecjuent use of alcohol, j)rotargol, or the nitrate 



HALLE'S FRONTAL SINUS OPERATION 



209 



of silver to retard granulations and to promote the formation of epithe- 
lium. At a later period Halle has the patient introduce a large cannula 
several times a day to prevent the formation of granulations and adhe- 
sions, though this should preferably be done by the removal of the 
granulations, caustic applications, etc., by the surgeon. 

(e) The anterior ethmoidal cells and middle turbinated body of the 
"vicious circle" are also removed in this operation. The posterior cells 
may also be removed at the same time by either of the methods de- 
scribed elsev^here in this chapter. 

Fig. 145 Fig. 146 




Fig. 145. — The first step in removing the nasal process which forms the floor of tlie frontal 
sinus at its inner extremity. A metal protector (a) is introduced into the frontonasal canal to 
Ijrevent injury to the inner or cranial wall of the frontal sinus. The pointed burr is only used to 
begin the operation, after which blunt, smooth-tipped burrs are used, as they will not penetrate 
the inner or cranial bony wall of the sinus if they should accidentally come in contact with it. 

Fig. 146. — The round-tipped burr removing the floor of the frontal sinus by the intranasal route. 
The protector is in position and the rounded, polished tip of the burr renders injury to the cranial 
wall of the sinus improbable. 



External Surgery of the Frontal Sinus. — On account of its location, 
the fi-oiital sinus is sometimes less successfully treated by the intranasal 
route than either of the other sinuses. We are, therefore, compelled to 
resort to external methods of operating in a considerable number of 
chronic cases. The method of Hajek Luc, or Ogston-Luc, as it is 
sometimes called, is one of the most efficient in uncomplicated cases of 
c:hronic empyema of the frontal sinus. This method is not adapted, 
however, to those cases in w^hicli the anterior ethmoidal cells are to l)e 
exente rated. In such cases it is necessary to remove the floor of the 
frontal sinus and the processus frontalis of the superior maxillary bone 
to give access to the anterior ethmoidal cells. The posterior ethmoidal 
and sphenoidal cells are accessil)le by the intranasal route. 
14 



210 



THE XOSE AXD ACCESSORY SIXUSES 



The Hajek-Luc Operation. — (a) The skin of the forehead and around 
tlie eve sliould he thoroughly cleansed twenty-four hours previous to 
the operation and covered v^ith a moist dressing. 

(6) Twenty four hours later the patient is placed upon the operating 
table and anesthetized. 

(c) The dressing is then removed and the parts re-scrubbed. It is 
not necessary to shave the eyebrow^ as it can be easily cleansed and is 
useful as a landmark. Personally, I prefer to shave the eyebrow, as it 
interferes with the removal of the stitches. 

Kk;. 147 Fio. 148 





Fig. 147. — The intranasal operation of Halle completed. The floor of the frontal sinus is 
wiilely opened and permits curettage and free drainage of the sinus. 

Fi<i. 148. — The Hajek-Luc operation. The anterior wall of the frontal sinus is removed, and 
the anterior ethmoidal cells are being removed through the floor of the frontal sinus with a curette. 
The left side has been operated, a gauze wick introduced through the anterior ethmoidal wound 
and drawn out through the nostril. 

(d) An incision is made, beginning at the temporal end of the eyebrow 
and extending to the median line of the head. The second incision is 
begun where the first leaves off, and extends upward as far as the upper 
limit of the frontal sinus, a fact which should be determined beforehand 
by .skiagraphy. 

(e) The skin and periosteum within this triangular incision are 
turned u])ward, thus exposing the outer plate of the frontal bone. 

(/) A liberal portion of the bone is then chiselled away, thus exposing 
the frontal sinus to inspection and probe examination. 

(r/) After determining the outline of the sinus and the degree and 
location of })athol()gical lesions, the morbid material is removed with a 
curette, and if bony septa are ])resent they are broken down (Fig. 148). 

(/?) The frontonasal canal must be enlarged as much as possible, to 
establish free drainage into the nose. This is done by breaking down 



HALLE'S FRONTAL SINUS OPERATION 211 

the anterior ethmoidal cells with a curette, through the floor of the frontal 
sinus (Fig. 148). 

(i) A large rubber tube is inserted into the frontonasal wound and 
left in position for several weeks, or until all discharge ceases. The 
nasal end of the rubber tube is seized with forceps from time to time, 
and moved up and do^vn, to prevent adhesions. When all discharge 
ceases the tube is withdrawn through the nose. 

(y) After inserting the rubber tube into the frontonasal opening the 
external wound is closed and left to heal by primary intention. 

Advantages of the Operation. — The advantages of this method of 
operating are: (1) It avoids disfigurement, as the wound heals by primary 
intention; (2) the frontonasal canal is enlarged, the anterior ethmoidal 
cells eradicated; and (3) as they are invariably involved in frontal sinu- 
itis, this operation is advantageous, because they are opened and drained 
in its performance. 

Disadvantages of the Operation. — Relapse occurs in about 50 per cent, 
of the cases, because the curettement cannot be done thoroughly on 
account of the incomplete removal of the anterior wall. Suppuration 
of the scalp has been reported, and the operation has been followed 
by sinuitis on the opposite side. Severe intracranial complications 
have also been reported, Tilley citing one death in 5 cases. 

Lermoyez reports 9 cases with 8 relapses; 5 of the cases were subse- 
quently cured by Kuhnt's operation, 1 by the repetition of the Hajek-Luc 
operation, while 2 died of meningitis (slow septicemia). It appears, 
therefore, that this method, while apparently very simple, is sometimes 
followed by very serious sequels. In view of these facts, it is usually 
better to adopt Kuhnt's operation, or at least a combination of the two. 
Personally, I believe this operation fails in such a large percentage of 
cases because the obstruction in the "vicious circle" of the nose is not 
removed; indeed, it is probable that this latter procedure alone would 
have given far better results than that given in the above statistics for 
the Hajek-Luc operation. 

Kuhnt's Operation. — ^The object of Kuhnt's operation is to obliterate the 
frontal sinus by granulation from the bottom of the cavity. He resects 
the entire anterior wall (Hajek-Luc removes only a portion of it) and a 
portion of the floor or orbital wall. Curettement is thoroughly performed, 
but the frontonasal canal is not disturbed, as to do so may lead to re- 
infection of the sinus from the nasal fossa. Kuhnt does not close the 
external wound, but leaves it open for the introduction of the dressings 
and for drainage. A cure takes place in from three to six weeks. Re- 
lapse and sequels are rare, and recovery is the rule. 

Disadvantages. (1) External drainage and dressings must be continueii 
for several weeks. (2) When a cure is accomplished the patient is 
more or less disfigured. (8) The anterior ethmoidal cells are unopened, 
though they are always simultaneously involved. (4) ])i])lopia has 
frequendy followed, from injury of the pulley of the superior oblique 
muscle, or from inflammatory infiltration about the pulley or within the 
muscle. 



212 THE XOSE AXD ACCESSORY SIXUSES 

In America there are few patients who would tolerate the disfigure- 
ment attending the operation. Suits for malpractice would likely follow 
in a small percentage of the cases. The method is surgically correct, but 
unless the life of the patient is in immediate danger the surgeon is not 
justified in performing it. If this method of operating is elected the 
patient sliould l)e ])lainly informed as to the probable disfigurement, and 
liis consent obtained Ix'fore operating. 

The Kuhnt-Luc Operation. — This operation is a combination of the 
method of Kuhnt and Hajek-lAic and consists in the free removal of 
the anterior wall of the frontal sinus, the enlargement of the frontonasal 
canal, and the introduction of the funnel-shaped rubber tube, together 
with a closure of the primary skin incision. This gives a fairly good 
cosmetic result and frontonasal drainage and ablation of the anterior 
ethmoidal cells, as in the Hajek-Luc operation, while it avoids, in a 
measure, the disfigurement attending external drainage, as practised by 
Kuhnt. There is more or less depression of the skin caused by the 
removal of the bone, but this can be corrected, in a measure, by subse- 
ci[uent paraffin injections. 

The Osteoplastic Operation. — A modification of the operation just 
detailed consists in making an osteoplastic flap instead of chiselling 
away the outer bony wall. The bony flap is formed by making a narrow 
incision with a V-shaped chisel along the upper border of the supra- 
orbital ridge, for the whole length of the sinus. This incision may 
also be made with a narrow-bladed rongeur forceps, or the De Vilbiss 
bone-cutting forceps. After the bony incision is made it is enlarged 
somewhat at either extremity to admit two rongeur forceps, by means 
of which the bony plate is broken off and left attached to the soft 
tissue. Considerable care must be exercised in handling the bony 
flap and soft tissues while they are being retracted, lest they be separated. 
The next step in the operation consists in the incision of the membranous 
lining of the sinus and the removal of the floor of the sinus. This is 
followed by a very thorough curettement of the anterior ethmoidal 
sinuses through the floor of the frontal sinus. After carefully cleansing 
the sinuses the wound is packed with gauze moistened with the compound 
tincture of benzoin. The external wound is closed with sutin-es, and on 
the fifth or sixth day one or two of the centre stitches is removed and 
the dressing taken out. 

The object of this method of operating is the same as that of Kuhnt's 
()])eration. 'J^'he eye symptoms are also the same. As Canfield has 
pointed out, there may be some deformity on account of the osteoplastic 
flap being lifted outward at its lower border by adhesions at the upper 
border of the bone flap to the posterior wall of the sinus, and subsecjuent 
contraction of the same. Again, the lower border of the osteoplastic 
flap is lifted outward somewhat by the removal of the gauze dressing. 
The lower border of the osteoplastic flap thus dislocated sometimes forms 
a ridge, which may be removed or corrected by a secondary operation. 
I see no reason why the wound should be packed as described. A 
better plan would be to pass a small wick of gauze through the enlarged 



HALLE'S FRONTAL SINUS OPERATION 



213 



frontonasal opening, retaining it in position for a few days, and then 
withdrawn altogether. This would obviate opening the external incision, 
as recommended, and would give a better cosmetic effect. A thorough 
exenteration of the anterior ethmoidal cells and the establishment of 
good drainage will nearly always be followed by a cure of the disease. 
(See "Vicious Circle.") 

The Killian Operation. — Technique. — After having prepared the field 
of operation, and having administered a general anesthetic, an incision 
is made through the eyebrow (previously shaved), beginning at its 
temporal end and extending to the median line at the root of the nose 
then curving downward and outward below the base of the nasal bone 





Fig. 149. — The incision for tlie Killian frontal sinus operation. 

Fig. 1.50. — The Killian frontal sinus operation, o, probe introduced into the 6 frontal sinus 
and through the surgical opening in its floor; c, the tip of the probe showing through the surgical 
opening on the lateral wall of the bridge of the nose. 



(Fig. 149). A second incision may be made if the frontal sinus is very 
large, extending upward from the median line at the root of the nose, a"s 
far as the upper limit of the frontal sinus, as shown by the skiagraph 
or by transillumination (Fig. 150). 

The periosteal incisions are two in number. The upper one is made 
parallel with the supra-orbital margin and 5 mm. above it, extending from 
the temporal end of the skin incision to the median line of the nasal 
bones. It may be extended upward to the median line as far as the sec- 
ondary skin incision. The second periosteal incision begins internal to 
the attachment of the pulley of the superior oblicjue muscle (Fig. I.IO d), 
passes inward, then curves downward and outward, following the direction 



214 THE XOSE AXD ACCESSORY SIXUSES 

of the skin incision around the inner canthus of the eye. This incision 
passes over the processus frontahs of the maxillary bone. 

The soft parts, including the })eriosteura, are lifted from the bone, thus 
forming the skin and periosteal flaps, with the exception of the perios- 
teum covering the superciliary ridge, where it is left intact to prevent 
the dislodgement of the pulley of the superior oblique muscle. 

The frontonasal process and neighboring bone are chiselled away, 
thus leaving the bridge of bone, the superciliary ridge of the orbit. The 
entire anterior wall of the frontal sinus is removed with a chisel and 
rongeur forceps (Fig. 150). 

The cavity of the sinus thus exposed should be thoroughly inspected 
and curetted in all its ramifications. Killian insists that wlien the an- 
terior bony wall is removed the mucous membrane should not at once 
be disturbed, but that it should be left intact as long as possible, so as to 
avoid unnecessary infection of the woimd. He makes a small preliminarj'- 
opening through the bone, and then with a probe, introduced between 
the bone and mucoperiosteum, determmes the limitations of the frontal 
sinus. Having done this, he proceeds to remove all the bone necessary 
for its complete exposure. He then opens the membranous sinus and 
proceeds to inspect and curette it according to the conditions present. 




Ostrum's localizer for the pulley of the superior oblique muscle. 



The next step in the operation consists in the removal of the floor 
of the sinus, leaving a bridge of bone 5 or 6 mm. w^ide above the supra- 
orbital margin. This bridge is showai in Fig. 150 d. As the operation is 
one wdierein there is some danger of mjurying the pulley of the superior 
oblique muscle, great care should be exercised to avoid it. As the pulley 
is variously located, this is not an easy matter. Dr. Ostrum has devised 
a pulley marker (Fig. 151), which may be applied to the tissues marking 
the location of the pulley, so that in the event of its detachment it may 
be sutured to the marked point, and thus prevent strabismus. 

The opening around the processus frontalis may be enlarged upward 
and backward, to afford a better field for the curette ment of the other 
sinuses, especially the ethmoidal and sphenoidal. Still having regard 
for the nasal mucous membrane, the curette is introduced through the 
opening made by the removal of the processus frontalis (Fig. 150), and 
the curettement of the ethmoidal and sphenoidal cells is performed. 
The limits of the ethmoidal cells are not difficult to make out wdth the 
curette, as the septa between the cells are usually very thin and easily 
broken down. The bone of the os planum and of the cranial plates is 
of greater density and resistance, and need not be mistaken for the 
septa between the cells. 



THE SURGERY OF THE MAXILLARY SINUS 215 

As the hemorrhage is considerable, the operator must depend upon his 
knowledge of the anatomical relations, the conditions of the diseased 
parts, and his sense of touch, rather than upon sight in exenterating the 
ethmoidal and sphenoidal cells. Thoroughly cleanse the wound by irri- 
gations with normal salt or boracic acid solution, then dust with iodoform 
powder, and close the skin and periosteal incisions with sutures. 

A point in the after-treatment insisted upon by Killian is, that the 
patient should be placed upon his healthy side and forbidden to blow 
his nose. He must aspirate the secretions from the nose, and the nasal 
cavity should be inspected daily, carefully dressed, and exuberant 
granulations touched with the nit ate of silver. 

A few days after the operation, if secretions still come from the sinus, 
gentle pressure over the skin should be made to force it into the nasal 
cavity. The patient should be made to sniff or aspirate it into his throat. 
He should not be allowed to blow his nose, as to do so might force 
infected matter into the frontal cavity The deformity following the 
operation is usually of moderate degree, and often becomes less conspic- 
uous after a few months. The frontal sinus becomes more and more 
filled with granulation tissue, and the orbital fat pushes upward through 
the open floor of the sinus. In this way the depression becomes fairly 
well filled, except when the sinus is very large and deep. When the 
sinus is large and deep the disfigurement may be very great 

This radical method of procedure is less liable to injure the pulley 
of the superior oblique muscle than the Kuhnt-Luc operation, or 
the Kuhnt operation, on account of the manner in which the periosteal 
incision was made, the periosteum over the superciliary ridge serving 
to hold the pulley in its place. 

Taking all the facts into consideration, if the case is complicated by 
ethmoidal and sphenoidal disease and an external operation is deemed 
necessary, the Killian operation is the safest and least disfiguring of 
the external operations. 

Of seventy-five cases of frontal sinuitis in which the clinical diag- 
nosis was confirmed by skiagraphy, in only three (4 per cent.) did I 
find it necessary to perform the Killian operation, the others being 
cured by giving surgical attention to the structures within the "vicious 
circle" of the nose. Of the seven Killian operations performed by me 
six were cured, one not benefited. The deformity was almost nil except 
in one case. 

THE SURGERY OF THE MAXILLARY SINUS. 

Intranasal Operations.— The intranasal surgery of the antrum may 
include (a) the structures within the "key," or "vicious circle," and (b) the 
inferior turbinated body and the naso-antral wall. If the infundibu- 
lum is blocked by morbid tissue or by anatomical peculiarities, the same 
intranasal operation as described for frontal sinuitis may be performed 
(p. 205). In exceptional cases this will be sufficient to establish a healthy 
condition of the mucous membrane of the sinus. If, however, the mucous 



•210 



rllK XOSE AXD ACCESSOBY SfXUSES 



membnuie has iin(ler<j;()ne marked degenerative changes, it is usually 
necessary to remove the anterior eml of the inferior turbinated body and 
the naso-antral wall, or to perform an extranasal operation, as the 
Calchvell-Iyuc or the Denker operation. 




Krausp's aiit7'um trocar with obturator. 

Removal of the Naso-antral Wall. — This operation was first performed 
by llethi, and has had many advocates since then. Clinical experi- 
ence has shown that a small opening in the naso-antral wall quickly closes, 
whereas, a large one remains open permanently. Puncture and irrigation 
through a Krause cannula (Fig. 152) are often sufficient to effect a cure in 
acute and subacute inflammations of the sinus. The puncture should 
be made beneath the inferior turbinated body, as shown in Fig. 123. 
The canmila mav be introduced dailv under cocaine anesthesia, with little 




Vail's maxillary antrum operation. The fragment of the turbinal extending over the naso- 
antral opening should be removed with biting forceps. Vail prefers this method wherein a por- 
tion of the inferior turbinal is removed witli the saw .is it conserves the inferior turbinal function. 

discomfort to the ])atient. The irrigating solution may range all the way 
from normal salt and boric acid solutions to the more irritating solutions 
of /inc and iodine. The u.sefulness of this procedure is largely limited 
to dia<>nosis, lh()U<>"h it has some tlieraneiitic value as well. 



THE SURGERY OF THE MAXILLARY SIAWS 



21' 



Many instruments have been devised for the removal of the naso- 
antral wall, some of which enable the operator to do the work with ease 
and precision. The instruments which have given the best satisfaction 
are Vail's saw, Ostrum's forward cutting forceps. Wells' trocar and 
cannula rasp, and Corwin's chisels. 




The removal of ihe naso-antral wall with Vail's convex saw. a, mucous membrane flap dis- 
sected from the naso-antral wall to be turned on to the floor of the antrum; b, puncture through 
which the saw is introduced; c, the bony naso-antral wall removed with Vail's saw. 

Vail's Operation. — Vail's is perhaps the most ingenious and practical 
method for the removal of the naso-antral wall. His saw is slightly 
curved on the flat, and when introduced obliquely through the naso- 
antral wall makes a circular or oval incision, thus removing a large 
portion of the wall (Fig. 154), separating the nasal chamber from the 
antrum. 

Technique. — (a) Local anesthesia of the inferior turbinal and of the 
inferior and middle meatuses. 

(b) Remove the anterior half of the inferior turbinated body with 
the swivel knife or with scissors, or with the saw as it removes the 
naso-antral wall (Fig. 153). 




Vail's antrum 



(c) Puncture the naso-antral wall near the floor of the nose with 
Vail's perforator. 

{(l) Introduce the saw (Fig. 155) through the puncture and then make 
the circular or oval incision shown in Figs. 153 and 154. While the 
saw has a tendency to describe a circle, the size of the opening may l)e 



218 



THE XOSK AXD ACCESSORY SIXUSES 



regulated by tlie operator, as tlie l)one is thin. The opening should be 
made as large as possible, to overcome the tendency to closure. 

(e) If a mucous membrane flap is to be turned into the antrum to 
cover its floor, its anterior and posterior boundaries should be incised 
with a right angle knife or with the author's specially devised 



[L 



The aiithor's right-angle knife. 

swivel knife (Fig. 83). The upper boundary of the flap is made when 
the inferior turbinal is removed (Fig. 154). The miicoperiosteal flap 
should be separated from its bony attachment with a small periosteal 
elevator. Having separated the flap, the saw is introduced and the button 
of bone removed as described in the preceding paragraph, after which 
the flap is turned on to the floor of the antrum, which has been previously 
curetted to remove the granulation tissue. The flap hastens the process 
of r(^generation and epidermization. 

(/) The first dressing consists of iodoform gauze loosely packed in the 
maxillary sinus. It should be removed in from twenty-four to forty- 
eight hours. 




The author's method of removing the naso-antral wall with the turbinitome, after the removal 
of the anterior portion of the inferior turbinated body. The turbinitome is introduced through 
the naso-antral wall at 6, cuts upward and then forward to a, with the righi' angle blade turned 
horizontally into the maxillary antrum. When the anterior wall of the antrum is reached at a 
the blade is rotated downward as shown in the illustration and pulled forward, making the cut 
indicated by tlie perpendicular doited line. 

(r/) 111 the after-treatment gauze dressings should not be used. The 
cavity should be left open for drainage and ventilation. Every time the 
patient blows his nose he blows the antrum. The case should be watched, 
and if exuberant gntmilations form, they should be promptly reduced by 
the application of dehydrated chromic acid crystals or with some other 
caustic. 



THE SURGERY OF THE MAXILLARY SINUS 



219 



The Author's Operation. — (a) Local anesthesia. 

(h) Remove the anterior half of the inferior turbinal with the author's 
right-angle turbinal knife (Fig. 156). The knife should engage the tur- 
binal at about its middle, and then be drawn forward to its anterior 
extremity, thus removing the anterior half with one put of the instrument. 




Completing the removal of the naso-antral wall e with the author's turbinotome. The right- 
angle blade is introduced at the interior portion of the posterior perpendicular incision c, and 
drawn forward along the floor of the nose to d. 

(c) Introduce the same knife through the naso-antral wall at the 
posterior limit of the antrum near the floor of the nose. Then make 
an upward cut, a forward and a downward cut, as shovni in Fig. 157. 
The upward and forward cuts are made with the blade of the instru- 
ment at right angles to the naso-antral wall. When the forward cut 
is made the blade should be turned downward parallel with the naso- 
antral wall and pulled through it. The inferior incision remains to be 
made, and is done with the reverse knife, the knives coming in pairs. 
The knife is introduced into the posterior perpendicular incision (Fig. 
158) at the floor of the nose, and drawn forward along the floor of the 
nose to the anterior perpendicular incision, thus completing the removal 
of the naso-antral wall. Should the knife fail to remove the thickened 
lower portion of the wall, it may be removed with the Griinwald or 
other bone forceps. 



/>^ 



Myles' reverse chisels. 



(d) Loosely pack the antrum with iodoform gauze for from twenty- 
four to forty-eight hours. 

(e) The after-treatment consists in the reduction of exuberant granula- 
tion tissue with caustics. 

Other Methods. — Myles' barbed cannulas (Fig. 159) are well adapted 
to the removal of the naso-antral wall. The cannulas are pointed, and 



220 



THE XnSE AXD ACCESSORY SIXUSES 



may he puslu-d thr()U(i;h the wall and ])ulle(l l)ack again, the harhs cutting 
or tearing the thin hony partition away. This procedure is repeated 
until the whole or any part of the wall is removed. 




W.P.CRAOr CO. 

win's antrum chisel. 



W.R.CKAOr CO. 

Corwin's antrum chisel. 



Corwin's chisels (Figs. 100 and 101) are also admirable instruments for 
the removal of the wall. The projecting points enable the operator to 
engage them at an acute angle in the bony w^all. Chisels without these 
points are not easily engaged, as they would glide over the sin-face of 
the mucous membrane. 

Ostrum's forward cutting forceps (Fig. 102) may be used after punctur- 
ing the naso-antral wall. It posseses the advantage of the forward cut, 
a point of no inconsiderable importance in view of the fact that the 
anterior angle of the antrum is usually the seat of the greatest morbid 
lesion. 




Ostrum's forward cutting; antrum forcepi 



Wells' combination antrum perforator and rasp file answers an ad- 
mirable purpose for making an opening in the naso-antral wall. After 
jierforating the wall the sharp obturator is removed and the rasp is 
used to remove the remaining ])ortion of the wall, which it does with 
throughne.ss. I'he fragments of mucous membrane remaining are 
removed with sharp biting forceps (Fig. 103). 

The author's antrum swivel knife may I)e used to remove the na.so- 
antral wall, as shown in Fig. 104. 



THE SURGERY OF THE MAXILLARY SLKUS 



221 



Extranasal Operations. — (1) Alveolar; (2) Kuster; (3) Palatal; (4) 
Cakl well-Luc; (5) Denker; (6) Jansen. 

1 . The Alveolar or Cooper Operation. — The alveolar operation v^as for a 
long time a popular procedure. Tilley, of London, reports that of 300 
cases of antral disease seen during ten years, only one had sound teeth. 




Wells' trocar cannula rasp for removing the naso-antral wall. 
Fig. 164 




)f the 
iiiferidi 



itral wall with the author's antrum swivel knife, the 
al being previously removed. The removal is inadequate 



lie reports that of 27 cases drained by the alveolar route, 15 persisted 
in the use of tube and irrigation for from six months to ten years. Of 
these, .5 afterward elected the radical operation, which was followed by 
complete cure. Of 37 cases operated l)y the radical method, 34 were 
successful. lie also says tluit the alveolar route is indicated in recent 
cases (of a few months' standing) and in chronic cases as a ])reliininary 
measure. 



222 I'l^l'^ .VO.S/t AND ACCESSORY SINUSES 

Of the alveolar methods, the removal of a earious tooth, usually the 
secoud bieuspid or the first or second molar, is attended by the most 
hapjjy results. It is obvious, however, that this method is only applica- 
able when there is positive evidence that the tooth is diseased beyond 
hope of re})air. The conditions are rare, indeed, that justify the removal 
of a tooth that could be successfully treated by a dentist. Even should 
it be admitted that more perfect drainage can be obtained by the removal 
of a tooth, there are still other methods of establishing good drainage 
which do not retjuire the interference with an important physiological 
organ, or other essential structure of the head. Drainage by the re- 
moval of a tooth should, therefore, be limited to those cases in which a 
competent dentist states that the tooth cannot be saved, or it can be 
demonstrated that there is a carious fistula extending from it to the antral 
cavity. In such cases the tooth may be removed, and the opening thus 
made enlarged and its walls rendered smooth. Daily irrigations with 
warm boric acid solution may be used until the discharge ceases. The 
alveolar opening should be closed with a strip of gauze, saturated with 
the compound tincture of benzoin, until healing occurs, or with a tube 
made for the purpose. 

2. The Kuster Operation. — This operation has been in much favor, as 
the interior of the antrum of Highmore is thereby exposed, permitting 
inspection and curettement of its cavity. The operation consists in 
the removal of a major portion of the anterior wall of the antrum, as 
shown by Fig. 168 a and h. The opening is usually limited to the area 
of thin bone of the canine fossa, and should be large enough to admit 
the introduction of the index finger. With the head mirror, light is 
reflected into the cavity and its walls examined. The portion of the 
cavity which cannot be inspected should be thoroughly explored with a 
curved probe. 

If necrotic areas and granulation tissue are found they should be re- 
moved by thorough curettement. The preliminary step of the operation 
consists in the elevation of the upper lip and an incision at the labiogingi- 
val junction (Fig. 165). The incision is carried through the periosteum, 
and should be one and one-half inches in length. The periosteum is then 
dissected upward over the canine fossa and the upper lip pulled toward 
the eye with a retractor, after which the anterior wall should be removed 
with a chisel and rongeur bone forceps. The cavity should then be 
explored with a probe and the diseased mucous membrane and necrotic 
bone removed with the curette. If the antrum is divided by septa 
they should be broken down to convert it into one large cavity. 

Having thoroughly removed the morbid tissue the sinus is firmly 
packed with gauze saturated with the compound tincture of lienzoin, 
which may be left in position for six or eight days if the granulations 
are excessive. The end of the gauze should protrude through the labio- 
gingival incision to prevent closure of the wound. If there is marked 
suppuration the cavity should be irrigated daily and loosely packed to 
promote drainage. When complete healing has taken place the dress- 
ings are discontinued and the labiogingival opening allowed to close. 



THE SURGERY OF THE MAXILLARY SINUS 



223 



3. The Palatal Operation. — The palatal route may be dismissed without 
detailed description, as it is the most objectionable of all, being indirect 
and easily invaded by food and bacteria. It should be considered only 
when perforation is already present in this region as a result of a malig- 
nant or other disease. 

4. The Caldwell-Luc Operation. — This operation is, in most cases, 
preferable to the Kuster operation. By it the antrum is exposed as 
in the Kuster operation, and a large opening made through the 
naso-antral wall. The opening may be made with forceps, Vail's saw, 
Corwin's chisels or Myles' barbed cannulas through the nasal orifice. 
Preliminary to this, however, the anterior two-thirds of the inferior tur- 
binal should be removed. In making the naso-antral opening shown in 





Fig. 165. — The Caldwell-Luc operation. a, the incision at the labiogingival junction. 
Fig. 166. — Showing the relation of the ductus lacrymalis to the inferior turbinated body. 1, 
the ductus lacrymalis; 2, the maxillary sinus; 3, the inferior turbinated body. (After Bardeleben.) 



Fig. 167, care should be exercised to avoid injuring the lacrymal canal, 
which opens beneath and near the anterior end of the inferior turbinated 
body and passes forward and upward to the inner canthus of the eye 
(Fig. 166). In other words, the naso-antral opening should not be 
extended too far forward. 

Having completed the removal of the canine and noso-antral walls, and 
having removed all disea.sed tissue from the antrum, the cavity should be 
lightly packed with a strip of gauze, the end of which is brought out 
through the nose. The labiogingival incision should be sutured (Fig. 
167) and allowed to lieal by first intention. After the first dressing is 
removed it is usually imnecessary to repack the antrum, drainage being 
very successfully accomplished through the naso-antral wound. At the 



224 



THE XOSh- AXJ) ACCESSORY SIXUSES 



end of the .seeoud day the gauze (h-e.ssing should be removed tlu'ough the 
nose. The seeretions may be removed by foreibly blowing the nose. 

It has been elaimed that it is unneeessary to do either the Kuster or 
the Calihvell-Lue operation, the simple opening through the naso-antral 
wall being (juite suffieient. That the naso-antral opening is sufficient 
in a mimber of eases is true. In other cases, in which there is a pro- 
nounced degeneration of the mucous membrane and caries of the bony 
walls of the antrum it is necessary to do the Kuster operation first, 
and to ex])lore the antrum by ocular inspection and curettement, a 
})rocedure which camiot be successfully done through the nose. The 



Fig. 167 




'I'lie Caldwell- Liic operation, a b, clositifi the lahioKingival incision with the Kevenien needle 
(6); b, the anterior wall (canine fossa) of the maxillary antrum removed; c c, a strip of gauze 
extending through the maxillary antrum into the nasal chamber, tlie naso-antral wall being 
removed. 

('al(l\vell-I.uc operation (a combination of the two) should, therefore, 
be elected in those cases in whicli there is pronounced suppuration 
with granulation tissue or polypi in the middle meatus of the nose. If 
these ])r()cedures are carried out j)roperly and the suppuration continues, 
it is probable that the ethmoidal and possibly the frontal sinuses are 
also involved, and that some of the secretions from them drain into 
the aiiti-um. In that event jjroper attention should be given to the 
f)ther siinises. 

."). The Denker Operation. — Indications. — This operation is indicated 
in obstinate intUunmatory disease of the maxillary sinus, which does not 



THE SURGERY OF THE MAXILLARY SINUS 



yield either to the intranasal or to the Caldwell-Luc operation. In such 
a case the mucous membrane of the sinus may be very edematous and 
the seat of extensive granulations. 

The anterior angle of the sinus adjacent to the nose is often inaccess- 
ible to the curette, either through the nasal or the canine fossa wound, 
hence the failure of the intranasal and the Caldwell-Luc operations. 
As the edematous membrane and the granulations must be thoroughly 
removed to effect a cure, an operation should be adopted that will 
thoroughly expose the entire cav- 
ity to curettement. The Denker 
operation does it, and it accord- 
ingly has a place in the treat- 
ment of selected obstinate cases. 

Technique. ■ — (a) A general 
anesthetic should be given. 

(b) The patient should be 
placed in Rose's position, with 
the head hanging over the end 
of the table. 

(c) Postnasal tampons should 
be introduced to keep the blood 
from the throat and trachea. 

{d) Make the labiogingival in- 
cision as in the Caldwell-Luc 
operation, extending it to the 
median line (Fig. 167). 

{e) Elevate the soft tissues and 
periosteum over the canine fossa. 

(/) Remove the anterior wall 
(canine fossa) of the maxillary 
sinus as in the Kuster and Cald- 
well-Luc operations, and then 
remove the bridge of bone be- 
tween the canine fossa and the 

lower portion of the pyriform opening of the nose, as shown in Fig. 168. 
By thus extending the bony wound the anterior angle of the sinus is 
exposed to operative interference. 

{g) Through the opening thus made remove the edematous membrane 
and granulation tissue wherever they may be found. 

{h) Elevate the mucoperiosteum of the inferior meatus of the nose, 
and of the inferior turbinated body, with a small flat elevator so curved 
as to adapt it to the anatomical configuration of the parts. 

(?■) Incise the mucoperiosteum thus elevated and convert it into a rec- 
tangular flap to be turned outward on the floor of the sinus. 

(_/■) Remove the bony wall and the anterior portion of the denuded 

inferior turbinated bone with bone-cutting forceps, the mucoperiosteal 

flap being turned into the nasal chamber to prevent injuring it with 

the bone forceps. The opening through the naso-antral wall should be 

15 




The Denker-Antrum operation, a, the area of 
bone removed in the Kuster and the Caldwell-Luc 
operations. In the Denker operation additionel 
bone at the right of the dotted line (fe) is removed, 
from h to the pyriform aperture. 



226 THE XOSE AXD ACCESSORY SINUSES 

tjuite large, as in the Cald well-Luc operation. Otherwise it will soon 
become closed and defeat the purpose of the operation. 

{k) Turn the mucoperiosteal flap on to the sinus floor and hold it in 
position for twenty-four to forty-eight hours with an iodoform gauze 
dressing. 

(/) The after treatment, as in the Caldwell-lAic operation, consists 
in watching the case and reducing exuberant granulations with caustics 
as soon as they a])]K'ar. 

6. The Jansen Operation. — Jansen claims that if one of the sinuses is 
affected, all on that side of the head are affected; he therefore directs his 
attention to the entire labyrinth rather than to a particular subdivision of 
it. His position is probably extreme, although all the sinuses in many 
cases are more or less involved. The maxillary sinus may act as a 
reservoir, receiving the secretions from the anterior ethmoidal and frontal 
sinuses; or the sphenoidal sinus may be the primary seat of the disease, 
and the secretions from it discharging upon the upper surface of the 
middle turbinated body may excite a secondary sinuitis in the other sin- 
uses. A more rational explanation is that an obstructive lesion in the 
region of the midille turbinated body and the infundibulum often results 
in an interference with the drainage and ventilation of all the sinuses. 
The middle turbinal and the infundibulum often form the "key" to the 
etiology of sinus inflammations. 

In complicated cases, where all, or nearly all, of the sinuses are in- 
volved, either primarily or secondarily, an effort should be made to 
determine in which group of cells the lesion has its focal centre, and 
whether the obstruction is within the "vicious circle" of the nose. The 
operative procedure should then be directed to the particular group of 
cells involved, or to the hiatus and infundibulum if they are obstructed. 
Having established ventilation and drainage, the cells will often clear 
up with little or no other treatment. In other cases it is necessary 
to exenterate the entire labyrinth before a cure is effected. It is in these 
cases that Jansen's operation, or some modification of it, may be em- 
ployed. This operation is a modification or an elaboration of the 
Caldwell-Luc operation , and consists of the following steps : 

(a) The mouth and teeth should be carefully scrubbed, and the labio- 
gingival fdssa packed with strips of gauze to keep the secretions away from 
the operative field and from the trachea. 

(b) General anesthesia. 

(c The head of the patient should hang over the table to keep the 
blood from entering the trachea. 

(r/) The incision is made as in the Kuster and Caldwell-Luc operations, 
and the periosteum and soft tissues are elevated over the canine fossa. 

(c) The bony wall (canine fossa) of the sinus is removed with a chisel 
and rongeur forceps, thus exposing the cavity of the antrum to view. 
Palpation with the finger and exploration with the probe should also 
be practised. The diseased areas should be curetted, leaving as much 
as possible of the healthy mucous membrane, as it will be needed in 
the final regenerative process following the operation. 



THE SURGERY OF THE MAXILLARY SINUS 227 

(/) A mucous membrane flap may be made by an incision corre- 
sponding to the attachment of the inferior turbinated body, and one along 
the floor of the sinus, the two incisions uniting posteriorly, thus forming 
a long tongue-shaped flap. The tip of the flap is drawn forward and 
stitched to the buccal mucous membrane at the median extremity of the 
labiogingival incision. The bone of the middle and inferior turbinated 
bodies should be shelled out, leaving the mucous membrane of the nose 
as nearly intact as possible, to form a mucous membrane covering for 
the floor and anterior wall of the antrum. The little finger should be 
inserted into the nose for counterpressure while performing this step of 
the operation. 

The ethmoidal cells are curetted through the naso-antral wall via the 
canine fossa. The sphenoidal sinus is likewise curetted through the 
same route. The posterior ethmoidal and sphenoidal sinuses may, 
however, be more easily curetted by the intranasal route. 

Having curetted the posterior ethmoidal cells and the sphenoidal 
sinus through the naso-antral wall, and having made the mucous mem- 
brane flap referred to in the preceding paragraph, and having stitched 
it into place, the case is ready for the first dressing. A strip of 
gauze moistened with the compound tincture of benzoin should be loosely 
but carefully packed in the operated sinuses. If it is desired to leave 
the labiogingival incision open the gauze should be folded and left in 
the opening, as in the Kuster operation. If, on the other hand, the 
labiogingival incision is to be closed the end of the strip of gauze is 
placed in the naso-antral opening, a small suture attached to it, and 
brought out through the nostril. If this precaution is not taken it may 
be difficult to remove the dressing. The first dressing is left in posi- 
tion about five days. The wound is re-dressed every one or two days. 

The case should be carefully inspected at frequent intervals, all 
exuberant granulations reduced by the application of caustics or the 
actual cautery, and everything done to promote a clean, healthy, regen- 
erative process. The time required for complete healing varies from a 
few weeks to several months. 

The operation seems to be a very radical one, attended by much danger, 
and to require great skill. The anatomical relations should be studied 
on the cadaver before attempting to operate on the living subject. 
Some writers, notably Onodi, oppose Jansen in his claims as to the 
accessibility of the sphenoid by this route. Onodi says that in twenty- 
five skulls he was only able to reach the sphenoidal sinus by the antral 
route in three. One of Jansen 's former assistants told me that he was 
able to do so in all of the 200 skulls examined by him (Canfield). 

A possible source of danger is the internal carotid artery which runs 
along the outer wall of the sphenoidal sinus. If there is necrosis at 
this point the curette might pass through and wound the artery and 
cause a fatal hemorrhage. Such an accident is a remote possibility. 
After a limited experience with this operation, my impression is that 
it would be better and safer to exenterate the ethmoidal and sphenoidal 
sinuses and do a Caldwell-Luc operation a few weeks subsequently. 



228 '^V/J? .Y0.S7^ AXD ACCESSORY SIXUSES 

As inontionod elsewhere, there is less liability to meningitis if the 
intranasal snrgery is performed a few weeks prior to an external sinus 
operation. Furthermore, the intranasal route affords a more natural and 
a safer route to the posterior ethmoidal and sphenoidal sinuses. 

The operation is neetllessly erude, and the risk out of proportion to the 
good to ])e aeeomplished by it. A Cakhvell-Luc and the intranasal 
operation upon the ethmoidal and sphenoidal sinuses is a more com- 
mendable mode of procedure in pansinuitis. 

THE PARTIAL REMOVAL OF THE ETHMOIDAL CELLS. 

In some cases a single ethmoidal cell may be the seat of infection and 
iuHauunation, and it alone may require surgical interference. The bulla 
ethmoidalis is sometimes affected while all the other cells are apparently 
healthy. Ix.*ss frequently one of the other ethmoidal cells is involved, or 
the anterior cells may be the seat of infection while the posterior cells are 
free from infection, or the posterior cells may be affected and the anterior 
cells be normal. After locating the cell or cells involved, the middle tur- 
binated body (middle concha), or a portion of it, may be removed and 
the exposed wall of the diseased cells broken down with a curette or a 
Griinwald biting forceps. The cell thus opened may close by granula- 
tion in the process of repair, thus necessitating repeated curettements 
before a cure is established. 

If after repeated attempts a cure is not effected, it may become neces- 
sary to perform a more complete operation. 

THE EXENTERATION OF THE ETHMOID CELLS VIA THE 
INTRANASAL ROUTE. 

The complete removal of the anterior and posterior ethmoidal cells, 
while pi-actically feasible, is often physically impossible, on account of the 
anatomical location of some of the cells. Some are inaccessible on account 
of the frontonasal process of the maxillary bone, and in some instances one 
of the anterior ethmoidal cells extends over the orbital cavity (Fig. 142) 
and is surgically inaccessible. I have occasionally operated upon cases 
in which the posterior cells extended backward along the side of the 
sphenoidal cells, and have seen anatomical specimens in which they 
extended behind the sphenoidal cells. For these and other reasons the 
total exenteration of the ethmoidal cells is not always practicable. Hence, 
when the term total exenteration is used in reference to these cells, the 
idea I wish to convey is that they are removed as completely as possible. 

The indications for tlu^ complete exenteration of the etlnnoidal cells 
is the pi-esence of a persistent infection and inflammation of the mucous 
membrane of the entire grouj), which ol)stinately resists simpler methods 
of treatment. 

Technique. — (a) First induce c()m])lete local anesthesia by the local 
a]>j)licati()n of a 10 per cent, solution of cocaine 



THE EXENTERATION OF THE ETHMOID CELLS 



229 



(b) Remove the middle turbinated body as elsewhere described. 

(c) Next sever the posterior and superior attachments of the eth- 
moidal cells with the author's right-angle knife (Fig. 156), as shown in 
Fig. 176. The knife should be introduced into the middle meatus of 
the nose with the blade pointing downward (Fig. 169), and when the 
anterior wall of the sphenoid is reached the blade should be turned di- 
rectly outward and forced upward along the anterior wall of the sphenoid, 
severing the ethmoid cells from it. The blade is then drawn forward 
along the roof of the nose (Fig. 176), severing the cells from the plate of 
bone to which they are attached. The blade of the author's right-angle 
knife has a blunt end, and is of such length that it will not injure the 
orbital plate in making the incision just described, provided the operator 
exercises ordinary judgment and mechanical skill in using it. 




The author's right-angle turbinal knife introduced into the nasal chamber with its 
blade hanging downward. 



{d) The orbital attachment of the cells remains to be overcome. 
This is, perhaps, most easily and safely accomplished with a curette. 
The intercellular walls are very thin and friable, and break down under 
the gentle application of the curette. The scraping or cutting surface 
of the curette should be directed outward against the orbital wall (Figs. 
170 and 171) and drawn forward with short movements until the entire 
surface is comparatively smooth. The curettage should be so gently done 
that the mucous membrane and periosteum of the orbital wall are not 
injured or the orbital plate broken. This can be accomplished with com- 
parative safety to the orbital contents by an experienced and skilful oper- 
ator. An inexperienced or bungling operator might fracture or perforate 
the orbital plate and admit infectious microorganisms into the orbital 
cavity, with disastrous results. In an experience covering two hundred 
operations I have seen but one orbital involvement, and that was an em- 
physema of the eyelid, a condition which disappeared in forty-eight hours. 

{e) The after-treatment is important, as the final success or failure 
of the operation will largely depend upon it. If the patient is operated 
on in a hospital, as, indeed, lie should be, it may not be necessary to pack 



230 



THE XOSE AXD ACCESSORY STXUSES 



the nose witli fjauze, provided the house surgeon is competent to pack 
it if hemorrhage occurs. If profuse and persistent hemorrhage follows 
the operation the upper })ortion of the nasal chamber should be packed 
at once, the packing being removed in from twelve to thirty-six hours. 
If the primary hemorrhage is profuse, but ceases after a half-hour, or 




Curettage of the ethmoidal cells after the removal of the middle turbinated body. The cut- 
ting edge of the curette is directed upward and removes the cells from the cranial plate as far 
forward as the dotted line. 

in less time, the nose should not be packed. Indeed, avoid placing a 
firmly packed dressing in the upper portion of the nasal chamber when 
the circumstances warrant it, as the packing may be a greater danger 
than the operation. A firm packing may fracture the orbital plate, 




Curettage of the ethmoidal sinuses. Second step. The curette is turned outward against 
the orbital plate and breaks down the intercellular walls of the ethmoid cells, including the bulla 
ethmoidalis x and the line of attachment of the middle turbinated body. 

cause a retention of the secretions which may be forced into the orbital 
cavity, or the secretions may undergo rapid retrograde changes, become 
ab.sorbed,and cau.se to.xemia. Drainage and ventilation of the operated 
area are prime requisites, and should be maintained if possible. 

"^^Phe area of operation should be loo.sely ])aeke(l with cotton saturated 



THE EXENTERATION OF THE ETHMOID CELLS 



231 



with a 10 per cent, aqueous or glycerin solution of ichthyol for thirty 
minutes daily for one to two weeks. If granulations form they should 
be touched with carbolic acid. If foci of suppuration persist the areas 




The author's middle turbinal knives. 

should be probed to discover if there is a hidden cell from which the 
granulations spring. If such a cell is found its ostium of discharge 
should be enlarged and free drainage and ventilation established. The 
case should be watched several weeks, and in exceptional cases for months, 
or until all foci of infection are eradicated. 

Turbinectomy with the Author's Knife. — Inasmuch as the partial or 
complete removal of the middle turbinated body is frequently necessary to 
relieve muscular asthenopia (imbalance of the extra-ocular or intra-ocular 

Fig. 173 




The first step of the removal of the middle turbinal with the author's turbinal knife. 

muscles), and to establish drainage and ventilation of the nasal accessory 
sinuses, I have endeavored to devise some simple means to accomplish 
it. The turbinotome (Fig. 172), herewith presented, in a measure, solves 
the pro])l(Mn. 



232 



THE XnsE AXD ACCESSORY SIXUSES 



Technique of Turbinectomy. — (a) Cocaine anesthesia. 

(h) Introduce the curved bhule of the knife between the middle 
turbinal and the septum at the posterior extremity of the turbinated 
body (Fig. 173). 

(c) Then draw it forward along the line of attachment to the anterior 
end of the middle tin-l)inal, thus removing it in its entirety (Fig. 174). 

{([) Remove the severed portion of the turbinal with dressing forceps. 

{(') As the anterior and posterior ethmoidal arteries supply the middle 
turbinal, hemorrhage may be free and persistent. If the patient is in a 
hospital, no dressing other than a dusting powder of bismuth or bismu h- 
iodine need be applied. If, how^ever, the patient is sent home, and is 
not easily accessible to the operating surgeon or his assistant, the space 
between the line of attachment of the turbinal and the septum should 




The removal of the middle turbinal with the author's turbinal knife. 



be firmly packed with a strip of sterile gauze dusted with bismuth. 
This may be left in position for forty-eight hours. The nasal chamber 
should subsequently be kept free from secretions by daily irrigations 
with sterile normal salt .'■olution or by packing the nose lightly with a 
10 per cent, aqueous solution of ichthyol, which should be removed in 
twenty to thirty miuutes. 

The Author's Method of Removing the Ethmoidal Cells and Mid- 
dle Turbinal En Masse.— As the etlnnoidal cells have their chief fixed 
attachments on their outer (orbital) and up])er (cranial) walls (Fig. 175) 
it is possible to remove them and the middle turbinal en masse. The 
advantage of this procedure consists in the availability of the removed 
specimen for inspection. When thus removed the mucous membrane 
and bony walls of the cells may be examined microscopically and macro- 
scopically for pathological lesions. When the cells are exenterated with 
a biting forceps or curette, such examinations are impossible or greatly 
hindered. Inasmuch as our present knowledge of the diseased processes 
in this region is very imperfect, the value of a method whereby the tissues 



THE EXENTERATION OF THE ETHMOID CELLS 



233 



Fig. 175 
Cribiform Plate 



may be removed en masse is obvious. With the knowledge thus obtained 
the surgeon will more quickly mature his judgment as to the morbid pro- 
cesses and the best methods of treatment. 

I have removed the ethmoidal labyrinth by curettage (Fig. 170) in more 
than two hundred cases, and the clinical results have been uniformly satis- 
factory. The chief question involved is, Would a less radical exentera- 
tion have been equally satisfactory ? Judging by the reports of other 
surgeons, I infer that they have been fairly successful with less radical 
work. Judging by my own experience, I have not had as good results 
with partial exenteration of the cells as I have by the more radical 
operation. Thus far I have seen no unfavorable results following two 
hundred radical exenterations of the 
ethmoidal sinuses. I feel justified 
therefore, in presenting this method 
of removing the ethmoidal cells and 
middle turbinated body en masse. 

Indications. — The total removal 
of the ethmoidal cells and middle 
turbinal seems to be indicated in 
chronic suppuration complicated by 
polypi, or a narrow or occluded ol- 
factory fissure. When it is possible 
to widen the olfactory fissure sufB- 
ciently by the submucous resection of 
the septum, one indication for the 
radical exenteration of the ethmoidal 
labyrinth is removed. If, however, 
the suppuration and polypi continue 
in spite of the repeated incomplete 
operations with forceps or other in- 
struments, the radical operation 
herewith given may be adopted. 
Another indication for the total re- 
moval of the ethmoidal cells consists in the persistent formation of plas- 
tic adhesions between the septum and outer wall of the nose after the 
incomplete operations. I have often seen such formations after the 
partial removal of the cells, and it was only after a complete exentera- 
tion that they ceased to form. 

Caution. — It should be said that this operation should never be 
attempted by an inexperienced and unskilled surgeon. While an experi- 
enced and skilled surgeon may remove the ethmoidal cells from the 
cranial and orbital plates of bone with safety, one less experienced and 
skilled might break through either plate of bone and expose the cranial 
or orbital cavity to infection. I wish to state, however, that after a 
somewhat extended experience, I have had no difficulty in limiting the 
operation within the bounds of the cranial and orbital plates. I am 
guided by sight, the mental picture of the anatomical relations, and the 
sense of touch. The sense of touch is a very important guide, as the 




Schema showing the chief attachments of 
the ethmoidal cells E E to the cranial plate of 
the frontal above and to the inner orbital 
walls on the outer aspect. The ethmoid is 
not attached to the cribiform plate. It is 
obvious that if these two planes of attach- 
ment are severed that the ethmoid cells and 
the middle turbinals will be entirely detached. 



234 



THE XOSE AXD ACCESSORY SIXUSES 



resistance offered l)y the cranial and orbital plates is distinctly different 
from that offered hv the intercellular walls. The cell walls are ver\^ 
friable, wliereas (he cranial (in particular) and the orbital plates are 




The author's method of removing the middle turbinate and the ethmoid cells en masse. The 
shaded lines indicate tlie area of the ethmoid cells, the author's right-angle ethmoid knife making 
the incision along the cranial plate. 

firm and resisting. The orbital'plate is quite thin, however, and should 
be attacked with great care and moderation. 

Technique. — (a) Secure anesthesia with a freshly prepared 20 per cent, 
solution of cocaine. 




The incision along, the orbital plate with the author's curved ethmoid or turbinal knife. The 
shaded lines indicate the area incised with the knife. The heavy black line beneath the roof of 
the nose is the line of incision previously made with the right-angle knife. 

(h) Introduce the right-angle knife"(Fig. 156) into the nasal chamber, 
with its blade pointing toward the floor of the nose (Fig. 169). When 
the posterior end of tlu> middle turbinal is reached turn tlie blade out- 
ward until it stands horizontally. 



THE EXENTERATION OF THE ETHMOID CELLS 



235 



(c) Then engage the blade at the posterior attachment of the middle 
turbinal and cut upward along the anterior wall of the sphenoid, thus 
severing the ethmoidal cells from it. When it has reached the cranial 
plate draw it forward, shaving the ethmoid cells from it until near the 
anterior end of the middle turbinal (Fig. 176). 

At this point the tip of the blade should begin to lag behind the shank 
of the instrument, and finally slide from the tissues into the anterior 
space of the nasal chamber. 

By this procedure the ethmoidal cells are severed from the cranial 
plate and from the anterior wall of the sphenoidal sinus. 

{d) Next introduce the orbital plate knife beneath the posterior 
attachment of the middle turbinal (Fig. 177) and dissect upward along 
the anterior wall of the sphenoid to the cranial plate above, then dissect 
forward and sever the cells from the orbital plate until the whole outer 
attachment of the ethmoidal cells is separated, as shown by the area 




Schema showing the outlines of the ethmoid cells after their removal by the author's method. 



covered by the shaded lines in Fig. 176). The major portion of the 
ethmoidal cells and middle turbinal are thereby completely severed from 
their attachments. 

(e) Seize the anterior end of the middle turbinal with forceps and 
remove the severed mass from the nose. Fig. 178 shows the outline of 
the cells on the orbital wall after the removal of the mass. This area 
may be gently curetted to remove edematous or diseased membrane, 
and the remains of the bony intercellular walls. The cell walls are so 
friable that great delicacy of manipulation is necessary to remove them 
without breaking them in the operative procedure and in removing the 
mass from the nose. 

After-treatment. — The patient should remain in bed for from one to 
three days, having the operated area gently mopped every four hours 
with a 10 per cent, aqueous solution of ichthyol to prevent infection and 
promote the outward osmotic flow of serum. At the end of three days a 
10 per cent, glycerin solution of ichthyol may be used, as the tissues will 
then tolerate the more active osmotic action of the glycerin. By the 



236 THE XOSE AXD ACCESSORY SIXUSES 

osmotic action of the glycerin and the antiseptic action of the ichthyol 
the wound may be kept clean and free from infection. Watch for 
granulations and adhesive processes, and check them by the cautious 
application of dcliydratiMJ crystals of chromic acid. 



EXTERNAL OPERATIONS UPON THE ETHMOID SINUSES. 

Moure's External Ethmoid Operation. — This operation maybe per- 
fornu-d in those cases in which extensive necrosis and polypi are present 
in the ethmoidal region, as it exposes the fiekl of operation better than 
any other method of operation. It may also be used to expose large 
tumors in this region. 

Technique. — (a) The operation should be performed mider general 
anesthesia, though it may be done under local injections of Schleich's 
mixtin-e combined with local cocaine anesthesia of the nasal mucous 
membrane. 

P"iG. 179 




Moure's operation upon tlie anterior ethmoidal cells. The dotted line n indinates the area of 
Imiif ronio\eil fioiu tlie lateral wall of tlie nose to expose tlie cells. 

(6) In.sert postnasal tampons, one in either nostril, to prevent the blood 
entering the trachea. 

(c) Make an incision along the ridge of the nose from a point midway 
between the eyebrows, and extending it dowiiward to the nasal opening 
on the side to be operated, at the junction of the cutaneous septum 
with the ala or wing of the nose. 

(d) Elevate the soft tissues, including the periosteum, as shown in 
Fig. 179. 

(e) Resect the nasal bone and the frontal process of the maxilla, as 
shown in the area encircled by the dotted line (a) in Fig. 179. 

(/) Having thus exposed the ethmoidal labyrinth, the entire ethmoid 
region may be thoroughly exenterated with a curette. 

If the disease is well advanced, that is to say, if there are polypi 
and granulations, every vestige of the cells should be removed. The 
cranial plate, the os planum (paper plate of ethmoid) or orbital wall, 



EXTERNAL OPERATIONS UPON THE ETHMOID SINUSES 237 

and the lacrymal bone which is adjacent to the anterior cells should be 
gently but thoroughly curetted until they are smooth. In addition to 
these surfaces the ethmosphenoidal wall (posterior limit of the eth- 
moidal cells) should also be thoroughly curetted. If all these surfaces 
are cleared with the curette and the anterior and posterior ethmoidal 
labyrinths are separated from their attachments, the cells and the middle 
turbinated body may be removed through the nasal wound or through 
the anterior naris. 

(g) The exenterated space should be packed with a strip of gauze in 
front of the postnasal tampon on the operated side, and the postnasal 
tampon removed from the other side. 

(/i) Close the skin and periosteal incision with fine silkworm sutures. 




Exposure of the anteiior ethmoidal cells through the inner wall of the orbit. This method of 
procedure is adapted to those cases complicated by orbital cellulitis. 



(?') Watch the case, and should granulations spring up at any point 
touch them lightly with carbolic or chromic acid. Should points of sup- 
puration be located, probing should be done with a view to tracing them 
to their sources. If it is found to be an overlooked or inaccessible cell, 
as an anterior ethmoidal extending over the orbital cavity or a posterior 
ethmoidal extending to the lateral side of or behind the sphenoidal sinus, 
steps should he taken to maintain a patulous opening for drainage pur- 
poses. All granulations should be removed from the point of suppu- 
ration as raj)idly as they appear. Persistent after-treatment along this 
line will often be i-cwai'dcd by a cure of the case. 

Orbito-ethmoid Operation. — (a) Make the Killian incision and ele- 
vate the tissues and periosteum at the inner aspect of the orbit, as shown 
in Fig. 180. (b) Remove the nasoorljital plate of bone and curette the 
ethmoidal cells through the opening. The orbital cellular tissue should 
also be explored and the pus evacuated if present. Maintain external 



238 



THE XOSK AXD ACCESSORY SIXUSES 



drainage until llic (li.sc'liar<fc ceases, and allow the wound to heal by 
granulation from the bottom. 



(M21: 




The Smitllui^on sphenoid forceps 
Fig. 182 




HfiiioviiiK tlic anterior wall nf tljp splieTKiiilal siiuis willi the .Siuithuison forceps. The distal 
blade of the forceps i.-^ iiitioducod ihrouRh the usteuiu sphcnoidalo and the bony wall removed by 
successive bites. 



I^ ^ 




Myles' reverse sphenoidal chisels 



SPHENOIDAL OPERATIONS 239 



SPHENOIDAL OPERATIONS. 



The preliminary operative procedure for reaching the sphenoidal 
sinus consists of the complete ablation of the middle turbinated body, 
thus exposing the ostium sphenoidale to view. 

The anterior wall of the sinus may be removed with biting forceps 
(Figs. 181 and 182) or with Myles' reverse chisels (Fig. 183). The 
ostium sphenoidale is situated in the upper portion of the anterior wall 
near the septum and appears as a round or oval fenestrum. The sinus 
should be explored through it with a blunt probe, to determine the con- 
dition of its mucous membrane. If it is thickened, soft or spongy, or 
covered with granulation tissue it should be carefully but thoroughly 
scraped with a dull curette. The operator should bear in mind that the 
walls of the sphenoidal cavity are very thin, and that there is danger of 
perforating them and transmitting infection to the dura mater, the optic 
nerve and vessels, and the sheath of the internal carotid artery. These 
accidents will not occur if ordinary care is exercised in carrying out the 
details of the operation. Should severe hemorrhage occur the sinus 
should be packed with iodoform gauze for twenty-four to forty-eight 
hours (T. Passmore Bereus). 



CHAPTER XII. 

NASAL XKL'ROSES. NAS.AL HYDRORRHEA. CEROBROSPINAL 
RHINORRHEA. 

NEUROSES OF OLFACTION. 

'i'jii: neuroses of olfaction arc characterized by cither (a) a perverted 
sense of smell (parosmia), (6) oversensitiveness to olfactory stimuli 
(hyperosmia), (c) a partial loss of the sense of smell (hyposmia), or 
{(I) total loss of the sense of smell (anosmia). 

Parosmia. — Parosmia is characterized by a perception of imaginary 
odors. The j^erversion of the sense of smell may be due to pathological 
changes in the olfactory brain centre. Inflammatory disease of the 
mucous membrane in the attic of the nose may also produce parosmia 
by overstimulating the nerve endings. It is usually found in central 
brain lesions, although it occasionally occurs in hysteria, hypochondria, 
epilepsy, insanity, and syphilis. 

Hyperosmia. — Hyperosmia is characterized l)y an oversensitiveness 
to olfactory stimuli — that is, the perception of odors is exaggerated. 
The most delicate perfinnes or odors not ordinarily perceived are recog- 
nized even to the point of unpleasantness. In some cases the perception 
of odors persists after the source of the odor is removed, and in this 
respect the condition approaches parosmia. 

It may be due to an irritation of the olfactory lobes, hysteria, neuras- 
thenia, hypochondria, sexual disorders in women (especially at the 
meiistrual period), and to the lowered nervous forces accompanying 
wasting diseases. 

Hyposmia. — Hyposmia is characterized by a partial loss of smell, 
cither from an impairment of the mucous membrane of the attic of the 
nose, the nerve endings, the bulb, or the brain centre. The impairment 
is only great enough to olitund the perception of odors without totally 
destroying it. 

Anosmia. — Anosmia is characterized by a total loss of the sense of 
smell, the pathological lesion being more extensive than that found in 
hy})osmia. 

1 have often seen cases in which there was a total loss of smell due to 
a l)locking of the olfactory fissure by an enlarged middle turbinal, which 
was relieved by the removal of the middle turbinal. These cases were also 
complicated by ethinoiditis and sphcnoiditis, but the loss of the sense 
of smell was not due to the inflanunatory disease, as the ability to perceive 
odors was immediately restored by the removal of the middle turbinate. 
If it had been due to disease of the mucous membrane, considerable 



SENSORY, VASOMOTOR AND REFLEX NEUROSES 241 

time would have elapsed before regeneration could have taken lace. A 
cold in the head is a frequent cause of transient anosmia. 

Odors reach the attic of the nose by either the anterior or the posterior 
nares, hence any condition of the septum or of the tissues of the outer wall 
of the nose which blocks the anterior or posterior nares produces anosmia. 
The lesion may be in the nerve endings, as in atrophic rhinitis, in the 
nerve, or in the olfactory brain centre. Anosmia of intranasal origin 
may be unilateral or bilateral according to the location of the obstructive 
lesion. In such cases the sense of smell may be restored by the proper 
surgical procedure within the nose. If, however, the lesion is in the 
olfactory nerve or brain centre a cure is scarcely possible. 



SENSORY, VASOMOTOR AND REFLEX NEUROSES. 

Hyperesthetic Rhinitis; Hay Fever. — ^Hyperesthetic rhinitis, or hay 
fever, is characterized by annual paroxysms of sneezing accompanied by 
a severe and prolonged coryza and asthma. 

Etiology. — The Predisposing Causes. — ^The predisposing causes of 
hyperesthetic rhinitis are constitutional, local, climatic, geographical, 
racial, and altitudmal. 

(a) The constitutional causes are a neurotic temperament, chemical 
changes in the mucus secreting glands (D. Braden Kyle), gout, and 
rheumatism. 

The neurotic temperament is difficult to define, but seems to consist in 
an unstable condition of the nervous system, wherein there is either an 
excess or a decrease in the nervous energy. Some claim that the 
nervous disturbance is due to a faulty metabolism whereby certain 
toxic substances are liberated in the blood current. Thus a gouty or a 
rheumatic diathesis is held to be the basic cause. It is obvious, however, 
that there must be a cause back of the gouty or rheumatic expression. 
It appears impossible in the present state of our knowledge to clearly 
define the conditions back of a nervous temperament. That hay 
fever subjects are neurotic is generally accepted. As to why they are 
neurotic is a much mooted question, concerning which many ingenious 
theories have been advanced, but none of which are convincing. 

(6) The local causes of hyperesthetic rhinitis are various. A perfectly 
healthy nasal mucous membrane on a normally placed bony frame- 
work is not often affected })y hay fever. On the other hand an apparently 
healthy mucous membrane on a normally placed bony framework may 
be affected by hay fever. I have seen cases in which there was no 
obstructive septal deformity and no absolute occlusion of the olfactory 
fissure by turbinal enlargement. The only noticeable morbid lesion 
was a slight redness of the mucous membrane over the anterior end of the 
middle turbinated bone. These cases were also subject to occasional 
attacks of severe coryza with copious purulent discharge. During the 
interim between the attacks of coryza no symptoms were complained of, 
but an examination of the nose showed the reddened and slightly boggy 
16 



242 THE NOSE AND ACCESSORY SINUSES 

condition of the anterior portion of the middle turbinal. While I do 
not care to promnlgate a new theory as to the etiology of hay fever, I 
have been impressed with the possible relationship of catarrhal sinuitis, 
])articularly ethmoidal and frontal, to hay fever. In some cases the 
surgical treatment of the sinuitis was followed by a relief of the hay 
fever. It is possible that the catarrlial discharge so irritates the nasal 
mucous membrane as to make it susceptible to the irritation of the pollen 
of certain plants and grasses. The difficulties in the way of diagnos- 
ticating catarrhal sinuitis have been so great that its presence has 
usually been overlooked. With our present knowledge its detection 
should be more often made. It is now possible, therefore, to study the 
relationship existing between sinuitis and hay fever, and I have some 
confidence that such a relationship will be satisfactorily established. 

Deflection of the septum, especially in the region of the middle turbinal, 
or enlargement of the middle turbinal, causing contact between the two, 
is another local factor in hyperesthetic rhinitis. 

The "sneezing area" of the nose is at the points of contact between 
the middle turbinal and the septum, hence the sneezing so characteristic 
of this disease. As a rule the moment the pressure is relieved the sneez- 
ing ceases. 

Sensitive areas on the nasal mucous membrane of the septum and 
the outer walls of the nose, reddened and slightly elevated above 
the surface of the mucous membrane, predispose to the hyperesthetic 
paroxysms. AVliether they are due to some concurrent inflammatory 
disease of the nasal and accessory sinus mucosa, or to some change in 
the sensitive nasal branches of the sphenopalatine ganglion, is not estab- 
lished. It seems reasonable to suppose that an inflammatory disease 
of the nose, attended by an irritating secretion, so characteristic of catar- 
rhal sinuitis, might affect the terminal sensitive nerve filaments, render- 
ing them extremely hypersensitive. The local vasomotor disturbance ; 
in the same areas would cause their elevation above the gurface of the 
mucous membrane. 

Dr. Schadle, of St. Paid, recently called attention to the possible rela- 
tionship existing between maxillary sinuitis and hay fever. Whether or 
not such a relationship actually exists, we must recognize the fact that 
the local hyperesthesia probably has an anatomical or inflammatory 
origin. The hypersensitiveness does not "happen;" it has a definite 
cause. Inasmuch as sinuitis, either catarrhal or suppurative, is often 
associated with hay fever, it seems plausible to conclude that the irri- 
tation attending the discharge of the secretions over the nasal mucous 
membrane may be the cause. The hypothesis is still further supported 
by the clinical fact that some cases of hay fever are cured by curing the 
sinuitis. 

While the above hypothesis is based upon clinical observations, they 
are too meagre to warrant final conclusions. They are sufficient, how- 
ever, to justify the closest scrutiny of the sinuses in every case of hyper- 
esthetic rhinitis (hay fever). Such a scrutiny should include the examina- 
tion of the middle turbinal, the olfactory fissure, the septum, the trans- 



SENSORY, VASOMOTOR AND REFLEX NEUROSES 243 

illumination of the sinuses, and a skiagraph of the sinuses. In addition 
the patient should be closely questioned concerning the presence of 
headache (chiefly frontal), dizziness, especially upon stooping forward, 
and unilateral disturbances of the ocular apparatus. The ocular dis- 
turbances may include errors of refraction, ulcer of the cornea, or 
lesions of the retina or other portions of the optic tract, and of any other 
of the structures of the eyeball. The composite picture thus elicited 
should show conclusively either the presence or absence of an associated 
sinus disease. 

Polypi have long been referred to as a local predisposing cause of 
hay fever. As these morbid growths are often secondary expressions 
of sinuitis, the possible causative relationship of this disease is thereby 
strengthened. The polypi usually arise from the region of the hiatus 
semilunaris, the border of the middle turbinal, or the posterior ethmoidal 
cells. 

In the latter event they protrude through the olfactory fissure into the 
middle meatus or are lodged above the middle turbinal in the superior 
meatus. The pressure due to their presence may be sufficient to irritate 
the sensitive mucosa, or the accumulated secretions from the sinus may 
be the exciting cause. It is evident that the mere removal of the polypi 
may not be sufficient to completely remove the irritation. The diseased 
sinuses should also receive appropriate treatment. 

(c) The climatic influence upon hay fever is well recognized as being 
confined to the neighborhood of the forty-fifth parallel of the northern 
hemisphere. The territory a few degrees either north or south of this 
latitude is comparatively free from this disease. This probably is due to 
the absence of the flora the pollen of which is the chief exciting cause. If 
a map of the United States were divided into four belts by lines drawn 
through it from east to west the majority of the cases of hay fever would 
be included within the third belt from the bottom, although many cases 
would be found in the other belts. 

{d) The geographical distribution of hay fever is instructive. It 
exists in greater abundance in the United States than in any other country, 
while England takes the second place. It is also present in Germany 
and France, although in lesser numbers. 

(e) The racial influence in the predisposition to hay fever is marked. 
It is more common in the English-speaking races of the northern hemi- 
sphere, although it is more or less prevalent among the German and 
French people. 

(/) Altitude exerts considerable influence in the causation of hay 
fever, it being more prevalent in the low portions of the countries, while 
the higher altitudes are comparatively free from it. The annual pil- 
grimages made into the mountains in the northern portion of the Eastern 
States and into the cold, bracing atmosphere along the shores of Eake 
Superior and tlie northern shoi-es of I>ake Michigan arc eloquent with 
the benefits derived from altitudinal and climatic migrations. 

(cj) Age is an important factor in the causation of hay fever, it being 
most common between the twentieth and fortieth vears of life. 



244 THE NOSE AND ACCESSORY SINUSES 

The Exciting Causes. — It is generally accepted that the exciting 
cause (if hay fever or hyperesthetic rhinitis is the emanations from 
certain plants and animals. It was at one time thought that all cases 
were of vegeta])le origin in the haying season, hence the name hay fever. 
Subsequent observations have shown that the exciting cause may emanate 
from various plants and animals, chiefly the following: Graminacese, 
solidago virgo aurea (goldenrod), ambrosia artemisifefolia (rag-weed), 
cats, dogs, horses, and cows. The emanations from grasses and other 
plants, causing the paroxysmal symptoms, is probably the pollen. In 
1873, IMackley conducted a series of experiments with glycerin-covered 
glass plates and observed the rise and fall of the intensity of the symp- 
toms with the increase and decrease in the number of pollen within a 
given area on the plates. From these observations he established the 
pollen of certain plants as an exciting cause of the disease. Since then 
many observers have reported the emanations from animals as exciting 
causes. 

The season exerts a characteristic influence upon the occurrence of 
the paroxysmal attacks of hyperesthesia. This is due to the fact that 
the emanations from the plants can only occur during the time they throw 
olf their pollen. It occurs more frequently in August and September 
and less frequently in June, when the roses are in bloom. 

An analysis of the causes of hyperesthetic rhinitis resolves the etiology 
into three groups, as follows: (1) A constitutional or neurotic habit. 
(2) Local morbid lesions of the nose and accessory sinuses. (3) The 
poll(Mi of certain plants and emanations from certain animals. 

Pathology. — The structural changes in the affected nasal mucous 
mcml)rane consist in a hyperemia, edema, and after repeated attacks of 
hy{)erplasia of the turbinated bodies. The presence of nasal polypi in 
a hay fever case is scarcely to be considered a pathological lesion of this 
disease, but rather a result of sinus inflammation. The elevated hyper- 
sensitive areas are chiefly found at the terminal endings of the sensitive 
branches of the sphenopalatine ganglion, and are due to the increased 
hyperemia in these areas, while the hypersensitiveness is due to the 
irritation of the sensitive endings of the nerve fibers. 

If the disease were a pure neurosis there would be other nervous 
phenomena somewhat proportional to the intense paroxysms of the 
hay fever, whereas if it were a true inflammatory disease there w^ould be 
greater structural changes. The disease is more probably a combination 
of a moderate neurosis, with local morbid changes which give rise to 
the local ii'ritation of the nerve endings of the sensitive branches of the 
s])heno]Kdatine ganglion, upon which, at favorable seasons of the year, 
the ])ollen of certain plants and the emanations from certain animals 
impinge upon and give rise to the phenomena characteristic of hyper- 
estli(>tic rhinitis. 

Symptoms. — ^^Die symptoms of hay fever are those of an acute coryza, 
as malaise, elevation of temperature, sneezing, serous discharge, head- 
ache, etc., to which are added an itching in the region of the soft palate 
and the median j)alpebral commissures (inner canthi) of the eyes,"^and 



SENSORY, VASOMOTOR AND REFLEX NEUROSES 245 

asthma. The sneezmg is paroxysmal, and may be excited^by sHght 
draughts of air, bright sunhght, dust particles, and psychical impressions, 
as the consciousness of being observed by another person, or by the 
thought of his own condition. The sneezing is accompanied by profuse 
lacrymation and serous nasal secretion and by suffusion of the conjunctiva. 
The profuse serous discharge from the nasal mucosa is followed by a 
contraction of the swollen mucous membrane, which brings temporary 
relief. 

The serous secretion from the nose is acrid, and excoriates the alee 
of the nose and the upper lip. (I have observed the same phenomena in 
some sinus inflammations when pus was absent.) The secretions be- 
come seromucous and in some cases purulent in character. 

Intermittent or even alternate stenosis of the nose is present. During 
the continuance of the nasal stenosis the patient sujEfers from the paroxys- 
mal sneezing and asthma, and from headache, lacrymation, and diffi- 
dence. The diffidence is pronounced, the patient dreading the approach 
of another person, especially if he is a stranger or someone with whom 
he is ill at ease. 

The pharynx is often dry and painful upon deglutition. The tonsils 
are not usually inflamed, although they may be. 

Tinnitus aurium due to a swehing of the mucous membrane of the 
Eustachian tube is frequently present. 

The appetite is impaired and there is a corresponding loss of weight. 

Prognosis. — A guarded prognosis should always be given. So 
many methods of treatment have been promulgated, with the assurance 
of success, that have proved wholly inadequate, that I have become 
skeptical in reference to nearly all of them. Upon theoretical grounds 
it appears that if either one of the three major causes of the disease is 
removed a cure must follow. If, for instance, the local morbid lesions 
of the nose are overcome, the patient should be freed from the hay fever; 
if the neurotic habit is overcome, the hay fever should be cured; and if 
the patient is removed from the influence of the pollen, or is rendered 
immune by serums or antitoxins, he should be cured. Many a patient 
has been treated and operated upon with a view to the total removal of the 
local morbid lesions, but the hay fever paroxysms continued from year to 
year without abatement. Many a hay fever sufferer has been persist- 
ently treated for the neurosis, and the various dyscrasias causing it, without 
effect upon the hay fever; and many a patient has been sent year after 
year to the mountains or to the northern lakes without preventing the 
recurrence of the paroxysms the following year. On the contrary, a few 
patients have been cured permanently by recourse to one or more of the 
foregoing methods of treatment. The same is true of other methods 
of treatment; a few are cured while many are not benefited at all. A 
remedy that is efficacious in one subject is totally inert when applied 
in another. 

Either the existing ideas concerning the etiology or our methods 
of diagnosis of the local mor])id lesions are wrong — probably both. 
Notwithstanding all this, we can only act upon the knowledge now in 



246 THE NOSE AXD ACCESSORY SINUSES 

hand. We must, therefore, continue to remove the local morbid lesions 
from the nose as the most hopeful line of treatment, except the re- 
moval of the patient to a place where the pollen or other irritant 
peculiar to his case is absent; or we must administer a serum that is an 
antidote to the pollen in question. In the meantime our knowledge of 
the morbid processes in the nose and accessory sinuses is rapidly ad- 
vancing, and it may be that after a time we will be able to cure this 
elusive and distressing disease. 

Treatment. — The treatment may be divided into five groups: namely, 
(a) (lie treatment of the dyscrasias, (b) the removal of the local morbid 
processes in the nose and the accessory sinuses, (c) the removal of the 
patient from the influence of the pollen or other emanations acting as 
the exciting cause of the disease; (d) the immunization of the patient; 
and {(') the relief of acute symptoms. 

The Treatment of the Neuroses and Dyscrasias. — The treatment of 
neuroses and the dyscrasias of modern civilization is an undertaking- 
calculated to bewilder all but the veriest enthusiast. We are in a 
domain of pathological entities whose forms are shadowy and whose 
definitions are obscure. We are dealing with unknown quantities upon 
hypotheses not yet proved. Failure is the almost inevitable result. 
While all this is true, something may still be done to improve rheumatic 
and gouty diatheses and the ill-defined neurotic manifestations. The 
intestines and stomach can be flushed by lavage and by saline cathartics. 
The kidneys and skin can be made to eliminate more freely, and the 
hemoglobin of the blood can be raised so as to attract more oxygen. 
These and other processes may be stimulated or modified so that the 
neurotic state of the nervous system and the various constitutional 
disorders are in a degree improved. Indeed, the treatment should 
include some of these measures, although a cure may never be effected 
by them. 

Treatment of the Local Morbid Lesions. — (a) The circumscribed sensitive 
areas should be cauterized with a flat electrode raised to a white heat, 
without the use of a local anesthetic. The use of an anesthetic would 
make it impossible to locate the sensitive areas, and, furthermore, the 
cauterization is superficial and lasts only a fraction of a second. The 
current should be turned on until the point of the electrode is almost 
instantly brought to a white heat. It should then be introduced cold 
into the nose, a sensitive area located with it, and the current turned 
on by pressing the button on the electrode handle. The moment the 
white heat is seen in the nose the button should be released and 
the electrode removed. Another sensitive area should be located and 
cauterized in like manner. From four to five sensitive areas may 
b{! cauterized at a sitting. The treatment may be repeated in from 
five to seven days. 

(h) Nasal catarrh, if present, should be treated during the period 
of quiescence, that is, when the hyperesthetic rhinitis is not active. 
(See Various Forms of Chronic Rhinitis.) 

(c) Nasal }>()lypi should be removed in the period of quiescence, 



SENSORY, VASOMOTOR AND REFLEX NEUROSES 247 

although they may be removed durmg the acute paroxysms. (See Nasal 
Polypi or Myxoma.) 

(d) Deviations of the septum causing any type of rhinitis, or that 
contribute to the causation of sinuitis, should be corrected during 
the period of quiescence, according to the methods described under 
Deviations of the Septum. 

(e) Sinuitis, either catarrhal or suppurative, should be treated during 
the period of quiescence, according to the methods described under the 
Inflammatory Diseases of the Nasal Accessory Sinuses. 

Dr. Schadle, of St. Paul, has reported very favorable results from 
irrigating the maxillary sinus. A saponaceous substance is washed away, 
the fluid finally coming away perfectly clear. Dr. Schadle suspects 
that the ostium maxillare is large and admits the irritating substances 
which excite the paroxysmal attacks, and that when washed from the 
antrum the symptoms are relieved. 

I have had equally good results follow the total exenteration of the eth- 
moidal labyrinth via the nose with a curette. One patient was compelled 
for three months each year to sleep in a sitting posture with her head 
upon a table. Since the radical removal of her ethmoidal sinuses the 
only manifestation of the old trouble is a mild asthma, which appears 
for short intervals at any season of the year. I have since performed a 
double Killian frontal sinus operation upon this patient with complete 
success. This operation has apparently had no influence on the slight 
asthma remaining. 

It is obvious that it is inadvisable to treat the local morbid lesions 
by surgical measures during the acute exacerbations, as to do so might 
subject the nasal tissues to violent reactionary inflammation and to 
septic infection. 

The Protection of the Patient from the Pollen or Other Emanations 
Exciting the Acute Paroxysms. — (a) Small, soft sponges may be worn 
in the vestibule of the nose to filter the pollen and other irritating sub- 
stances from the inspired air. They are sometimes effective, but, on 
the whole, are unsatisfactory. A moistened handkerchief may also be 
utilized for the same purpose by holding it close to the nasal openings. 
At best, these devices afford temporary relief, and cannot be depended 
upon throughout the paroxysmal period. 

(b) The geographical treatment consists in the removal of the patient 
to a place where the exciting emanations are absent. The Lake Superior, 
or the Muskoka region in Canada, and the Adirondack Mountains 
are favorite resorts for many patients in the United States and Canada. 
An extended ocean or lake trip is also a satisfactory method of escaping 
from the emanations of the irritant pollen, etc. 

While the geographical treatment is not always effective, it is nearly 
always so if protracted over the entire period of the acute exacerbations. 
Some cases may return before the expiration of this period without 
experiencing a recrudescence of the acute symptoms, although this is 
rarely so. Others are not relieved by a change of geographical location; 
at least, all cases are not relieved by a change to the same locality. Each 



248 THE XOSE AXD ACCESSORY SIXUSES 

case must learn l)y experience the place best suited for him. On the 
other liand, he may find relief for a number of seasons in one locality, 
and upon returning the following year may experience but little or no 
relief. Under these circumstances he should try another locality. If, 
for instance, he has been going to the Lake Superior region or the 
]Muskoka Lake region, he should be sent to a higher altitude as the 
Adirondacks or the Rocky ^Mountains. 

The Palliative Treatment. — "\'arious local and internal remedies have 
been advocated, but none of them are of universal value. They may 
be tried in series in individual cases until one is found that gives 
relief. 

(a) The extract of the suprarenal gland is often successfully used. 
It should be prepared, according to Dr. H. L. Swain, by adding 10 to 
20 grains of the powdered gland to one-half dram of cold, sterile water. 
After stirring thoroughly, it should be filtered and a few drops of alcohol 
added to prevent early decomposition. Boric acid, cinnamon-water, and 
camphor-water may also be used to prevent decomposition. When 
thus prepared it should be applied to the nasal mucous membrane with 
a spray tube, or with thin pledgets of cotton pasted over the surface of 
the mucous membrane. It is harmless, except in those occasional cases 
in which it excites irritation and sneezing. S. Solis Cohen has used it 
internally with success. 

(h) The powdered sidphate of quinine insufflated into the nose has 
been recommended. I have used it in a few cases with complete success, 
and in many others without result. When it is effective the nasal 
mucous membrane becomes dry and the turgescence disappears. The 
ears ring from the absorption of the drug. In one case two insufflations 
of 5 grains each were followed by complete relief lasting throughout the 
paroxysmal season. This case was a mild one, beginning in the latter 
part of August. 

(c) Alkaline and oleaginous solutions may be sprayed into the nose, 
with transient relief. In some cases a postnasal douche of boric acid 
solution is grateful. Oil with menthol in 0.5 per cent, solution, or w^ith 
0.1 per cent, of formaldehyde, is sometimes grateful to the inflamed 
membrane. The formaldehyde burns for a few seconds and is followed 
by a grateful sense of relief. 

(d) The itching at the inner canthi of the eyes may be relieved by 
irrigating with boric acid or normal salt solution. 

(c) The rays of the 500 candle-power incandescent lamp (Fig. 19) 
applied for ten to twenty-five minutes over the face with the eyes closed, 
at a distance of from twelve to eighteen inches, increase the speed of 
the arterial venous currents. The passive congestion and edema are 
thereby reduced and the relief is considerable. (See Leukodescent 
liight and the Technique of Application.) The light should be applied 
from one to four times daily. In those cases in which its use is attended 
by marked relief a lamj) may be installed in the patient's home. A lower 
power than 500 candle-power is not recommended, nor is a cluster of 50 
can(IIe-])()wer lamps as eflicacious as a single 500 candle-power lamp. The 



SENSORY, VASOMOTOR AND REFLEX NEUROSES 249 

therapeutic value of the hght is chiefly determined by the candle-power of 
a single lamp, no matter how many are connected in a series or in a group. 

(/') Powdered diphtheria antitoxin has been used locally with gratifying 
resuUs (Pierce). Numerous other local remedies have been recommended 
from time to time, but have proved of little value after more extensive 
trial. 

(g) Antilithemic remedies, as the salicylate of soda, have been ex- 
tensively employed to counteract the uric acidemia with indifferent 
success except in occasional cases. 

Serum Treatment. — The serum treatment recently introduced by 
Dunbar, while not perfected, affords relief in selected cases. Sir Felix 
Seman, Liebreich, and Lobe endorse Dunbar's serum treatment, with the 
proviso that all the conditions recommended by him be observed. The 
serum is prepared in liquid and powdered form, the powdered being 
the most stable and reliable. The solution may be applied to the con- 
junctiva or the nasal mucous membrane. The object of the serum is to 
afford immediate relief and ultimately to establish immunity. The con- 
ditions attending its use are so complex that it is at present a rather 
unsatisfactory remedy. 

In my opinion, serum treatment will not prove to be the solution of 
the management of hay fever or its kindred types of hyperesthetic 
rhinitis. The predisposing factors are ignored in this method of treat- 
ment. There are conditions which render the mucous membrane of the 
nose susceptible to irritation by the toxins of the pollen which excite hay 
fever. Heretofore we have regarded the neuroses and constitutional 
dyscrasias, the various obstructive lesions of the septum, and the 
catarrhal affections of the nasal mucous membrane as the predisposing 
causes. The treatment applied in accordance with these ideas has 
generally been disappointing. In my opinion we must look beyond the 
nasal chambers to the accessory sinuses for the real conditions which 
predispose the mucous membrane of the nose to the irritation by the 
pollen of certain grasses, flowers, etc. The irritation caused by the 
more or less constant discharge from the sinuses is, to my mind, a 
rather common cause of hay fever. Schadle has called attention to the 
relief afforded by the irrigation of the maxillary sinuses. According to 
my observations the exenteration of the ethmoidal sinuses (including the 
removal of the middle turbinal) has given an apparent cure extending 
over two years. The sinuitis may or may not be purulent. Indeed, the 
catarrhal type is often more irritating than the purulent, as shown by 
the excoriations and fissures at the margin of the vestibule of the nose. 

In view of these facts I am inclined to the opinion that the ulti- 
mate cure of hyperesthetic rhinitis and asthma will not be found in the 
serum treatment, but will be found in the proper comprehension and 
treatment of catarrhal and suppurative sinuitis. This will include the 
obstructive lesions of tlie septum and the structures within the "vicious 
circle" of the nose. The neurotic element is often so marked in these 
cases that any method of treatment may fail. 

According to C). J. Stein the inj(H'tion of a few drops of alcohol into 



250 THE NOSE AND ACCESSORY SINUSES 

the mucous membrane of the nose at the points where the sensitive 
nerves enter the nasal chambers (Fig. 1) controls the acute symptoms 
in hay fever subjects. From three to four injections a few days apart 
is sufficient to control the attack throughout the season. 



ACUTE CIRCUMSCRIBED EDEMA OF THE NOSE. CORYZA EDEMA- 
TOSA. ACUTE CIRCUMSCRIBED EDEMA. 

This affection may also involve the pharynx and larynx in the same 
case. It is not an inflammatory infection, but is an edema of neurotic 
origin, probably from some disturbance of the digestive tract. It is 
quite like urticaria, though it involves the mucous membrane. It is 
usually associated with other symptoms or diseases, as hay fever, urticaria 
of the skin, headache, gastro-intestinal disturbances (as watery vomiting 
and colicky pains), and itching. In Matas' case a distinct periodicity 
was present, the edema recurring regularly between 11 and 12 a.m. 
daily. In this case the toxin was probably the malaria plasmodium. 

I reported a case in 1896 in which the angioneurotic edema came on 
during an attack of hay fever. There was also a gastro-intestinal dis- 
turbance. The edema involved the nose, soft palate, and hypopharjmx. 
The mucous membrane was swollen, gray, and semitranslucent. The 
suifocative symptoms were pronounced, although at no time was there 
imminent danger from this source. 

Numerous punctures of the edematous membrane were made and 
cocaine applied, after which the edema gradually disappeared. 



NASAL HYDRORRHEA. RHINAL HYDRORRHEA. 

Nasal hydrorrhea is a symptom of some other nasal lesion rather 
than a disease, and is characterized by thick, viscid, and slightly opales- 
cent secretion more or less rich in mucin. The amount of discharge 
varies from a few ounces to a pint or more in twenty-four hours. Ac- 
cording to St. Clair Thompson, the secretion contains amorphous 
matter and mucous corpuscles. "The addition of either alcohol or 
acetic acid throws down a stringy precipitate like mucin. On boiling 
the precipitate with dilute sulphuric acid, a reducing, sugar-like material 
is formed; this is also characteristic of mucin. The fluid contains a 
small amount of proteid coagulable by heat; it does not reduce Fehlin's 
solution. Proteoses and peptones are absent. The alcohol extract of 
the fluid contains no reducing substance. The presence of mucin and 
the absence of the reducing substance are quite sufficient to distinguish 
this fluid from normal cerebrospinal fluid." 

Symptoms. — The clinical picture of nasal hydrorrhea shades off 
in one direction into cases of what are generally called hay fever, with 
symptoms of intense local irritation, while in the other direction they 
may consist of a passive and almost painless, watery discharge from the 



CEREBROSPINAL RHINORRHEA 251 

nose. It appears to be an affection of adult life affecting males and 
females indifferently. Although it may be more marked on one side 
than on the other, the flow usually takes place from both nostrils. 
When handkerchiefs are soaked with it they generally dry stiff. In 
cerebrospinal rhinorrhea, on the other hand, the discharge is so watery 
that handkerchiefs dry quite soft, and can be used again without washing; 
and in this affection the discharge is limited entirely to one nostril, unless 
there happens to be some obstruction on the affected side, when it may 
make its way round to the opposite nasal fossa. When the fluid is of 
arachnoid origin there is frequently headache or other mental symptoms 
which are relieved by the discharge. It is not accompanied with lacry- 
mation or suffusion of the conjunctiva, and photophobia; and although 
it may occasionally give rise to a little sneezing, especially in the morn- 
ing, or on rising, this is a rare and infrequent accompaniment. 

In nasal hydrorrhea, feelings of malaise set in with the discharge 
and only disappear with its cessation. It is frequently ushered in with 
sneezing, photophobia, and lacrymation. It rarely continues in sleep, 
while cerebrospinal rhinorrhea continues day and night. It is very 
erratic in its onset and in its intermission, and it is very dependent on 
external influences and on conditions of health. Moritz Schmidt states 
that some cases have been observed which were dependent on ulcer 
of the stomach or biliary lithiasis and while using the term which 
forms the title to this paper, he defines the disease as a vasomotor 
rhinitis. McBride recognizes the diversity of the conditions of which 
nasal hydrorrhea may be but a symptom. 

Treatment. ^ — The treatment should be addressed to the morbid 
nasal lesions, such as are found in hay fever or other forms of hyper- 
esthetic rhinitis, or to any other pathological condition present in the 



CEREBROSPINAL RHINORRHEA. 

St. Clair Thompson, in 1899, made a notable contribution to 
rhinological literature when he described for the first time the escape 
of cerebrospinal fluid from the nose. Such cases had been previously 
regarded as nasal hydrorrhea. Thompson's analysis of his and other 
cases recorded in the literature under various names made the differ- 
ential diagnosis between cerebrospinal rhinorrhea and nasal hydrorrhea 
quite clear. The subarachnoid fluid may, under conditions not yet 
clearly demonstrated, escape from the cranial cavity through the nose 
without apparent harm to the patient. The fluid is clear and watery 
in contrast to the slightly opalescent and viscid fluid of nasal hydrorrhea. 
The dripping is constant and is free from taste, sediment, and smell, 
and it is fi'ee from albimiin and mucin. It reduces Fehling's solution. 

Etiology. — The etiology is as yet but little understood, although 
Thompson is inclined to the belief that there is some pathological 
change in the contents of the skull leading to increased intracranial 
prcssin-e. In 17 out of 21 cases recorded there were cerebral symptoms, 



252 THE NOSE AXD ACCESSORY SIXUSES 

while 8 showed retinal clianges. The following table prepared by 
St. Clair Thompson gives the essential tests for cerebrospinal fluid: 

1. The fluid is j^erfectly transparent like water, and contains no 
sediment. 

2. It is faintlv alkaline in reaction, and either tasteless or slightly 
.salt. 

'.i. The specific gravity is between 1005 and 1010. 

4. It is not viscid, and gives no precipitate (mucin) on adding acetic 
acid. 

5. On boiling there is not more than a trace of coagulum of serum 
globulin and serum albumin. 

6. ('old nitric acid gives a ])re('ipitate which disappears on heating, and 
separates again on cooling. 

7. Saturation with magnesium sulphate should give a precipitate. 
Saturation with sodium chloride should also produce a precipitate. 
Anunonium sulphate should be tried if the above salts fail. 

8. The liquid should give a pink or rosebud color with a trace of copper 
sulphate and excess of caustic potash. 

9. When boiled with Fehling's solution there shoidd be a reduction 
of the copper (due to pyrocatechin or some similar body). 

10. The reducing substance may be ol)tained by evaporating to dry- 
ness an alcoholic extract of the fluid. It is then found in the form 
of needle-like crystals. 

11. The aqueous solution of this residue does not ferment with yeast. 
If applied to suspected cases, these tests will in future avoid any 

question as to the true nature of cerebrospinal fluid when it escapes 
from the nose. 

Treatment. — The treatment of cerebrospinal rhinorrhea is obviously 
next to ini])ossible. Whatever is done, extreme care should be exercised 
to avoid infection of the nose, as it might be communicated to the men- 
inges or to the cerebrospinal fluid of the brain and spinal cord. 



ASTHMA. 

Asthma may or may not be of nasal origin. The bulbar nuclei of the 
fifth nerve has an anatomical connection with the vagus, hence it is 
possible for an irritation in the nose to excite reflex phenomena in the 
lower respiratory tract. The most common cause of asthma of nasal 
origin is polypi; at least, larger numbers of cases cured by intranasal 
treatments are cured by removing polypi. In other cases hypertrophy, 
hypei-])lasia, and other morbid lesions appear to cause asthma. On the 
other hand, they are more often present without exciting asthma. 

Treatment. — The treatment of asthma of nasal origin consists in 
(he correction of the nasal morbid lesions, more especially if they are 
j)()lypi or hypertrophy of the turbinated bodies. (See Ethmoid Opera- 
tions.) 

A useful t(>st as to the curability of the case is to apply a solution of 



EPILEPSY OF NASAL ORIGIN 253 

cocaine to the mucous membrane of the nose, and if the asthma is greatly 
reheved or akogether checked, it is probable that the removal of the 
morbid lesions will result in a cure, though this cannot be positively 
promised, nor can it be stated how long the relief will continue. 



EPILEPSY OF NASAL ORIGIN. 

Epilepsy of nasal origin has been reported by various authors. Watson 
Williams refers to a case of an epileptic attack brought on by cauter- 
izing the nose for nasal polypi. He also cites two cases reported by Baron, 
one in a case of nasal polypi, the removal of which was followed by 
marked alleviation of the epileptic seizures ; the other a young unmarried 
woman who had epileptic fits at her menstrual periods from the time 
menstruation began. Her inferior turbinated bodies were greatly 
hypertrophied, and she was always more troubled with nasal stenosis 
during the menstrual periods, and it was at these times only that the 
fits occurred. Removal of the hypertrophied tissue was followed by a 
cessation of the fits for seven or eight months, and when they reappeared 
the turbinal hypertrophy was found to have returned. 

I have a case of sarcoma of the nose, upon which I operated in April, 
1903, that has had repeated epileptic fits since the operation. In each 
instance I have found a sequestrum of bone in the ethmoid region near 
the cribriform plate, after the removal of which the fits failed to return 
for several weeks or a few months. 

Nasal Tachycardia. — Watson Williams, in his well-known treatise 
on Diseases of the Upper Respiratory Tract, cites the experiments of 
Gruber, and the reports of several cases as follows : 

"The effect of irritation of the nasal mucosa upon the movements of 
the heart and pulse have been studied by Gruber. He tested in all 43 
subjects, 13 with normal noses and 30 with nasal disease, and repeated 
his tests on several occasions in each. He found that irritation of the 
nasal mucosa was entirely negative. 

"I have never seen any instance of reflex influence on the heart from 
nasal disease, but Spencer Watson records a case of tachycardia which 
was associated with, and apparently due to, nasal polypi. Charsley 
observed temporary exophthalmos with tachycardia, the pulse ranging 
as high as 110 per minute, coming on and lasting for a period of three 
months after the galvanocauterization of one of the inferior turbinals. 
Symptoms of Graves' disease have been attributed to nasal disease; 
thus Hack, in a case associated with chronic rhinitis, found that the 
goitre and tachycardia vanished after treatment of the rhinitis, and B. 
Frankel and Hopmann report similar cases cured by nasal treatment." 



CHAPTER XIIL 

NEOPLASMS OF THE NOSE. 
MYXOMA; NASAL POLYPUS. 

Myxoma, or nasal polypus of the nose, is usually a pedunculated 
connective-tissue tumor most often growing from the middle turbinated 
body, the uncinate process of the ethmoid bone or the ethmoidal cells. 
It is usually significant of a preexisting catarrhal or suppurative inflam- 
mation of the sinuses. Some writers believe the tumor is primary and 
the inflammation of the sinuses secondary. Such a belief probably arose 
on account of the hazy conception of the symptoms of catarrhal sinuitis. 
Fortunately, catarrhal inflammation of the sinuses is now well under- 
stood, and I believe that clinical experience will show that the inflam- 
mation exists prior to the formation of the myxomatous tumors. 

Etiology. — While it has not been definitely proved that nasal polypi 
are directly due to sinuitis, it nevertheless often appears to be secondary 
to such an inflammation. If the cases are carefully studied, it will often 
be found that the patients complain of a vague frontal headache, pressure 
between the eyes, dizziness, especially upon stooping forward, irritability 
of the eyes upon prolonged reading, or a difficulty in the proper refraction 
of the eyes. Some or all of these and other symptoms are present in 
catarrhal as well as in suppurative sinuitis. It is claimed that repeated 
attaclvs of coryza may cause polypi. This is practically equivalent to 
saying they are due to sinuitis, as the distressing symptoms of coryza 
are usually due to the associated inflammation of the accessory sinuses. 
Clinically we know that polypi are often associated with suppurative 
sinuitis and with caries of the bone in the immediate neighborhood of 
the tumors. Some writers cite the fact, or apparent fact, that polypi 
are found in the less obstructed nasal cavity, as an argument against the 
previous existence of the sinuitis I believe that a careful examination 
of the nose will show that the polypi are usually present on the side of 
tlic nose in which there is the greatest ohstruction in the region of the middle 
turbinated body, or "vicious circle." A casual examination of these 
cases often shows a concavity on the side of the polypus, but the concavity 
is in the lower portion of the nasal chamber. A common type of septal 
deformity is shown in Fig. 184, in which there is a ridge on the inferior 
portion of the left side of the septum, while there is a convexity high up 
on the right side of the septum. It is easy to understand how the 
examination might show an open nostril on the right side in this instance, 
if only the lower portion of the nose were taken into consideration. If, 
however, the upper portion is considered the obstructive lesion is readily 
discovered on the side where polypi are present. 



MYXOMA; NASAL POLYPUS 



255 



One of the commonest causes of nasal polypi is a preexisting inflam- 
mation of the membrane of the nasal sinuses and of the nasal mucosa in 
the region of the cell openings. The irritation and pressure give rise 
to a passive congestion and a proliferation of cells. A serous or edema- 
tous infiltration is a later manifestation. The connective-tissue cells 
subsequently become filled with the serum, thus leading to a hydropic 
degenerative change in some cells, and a myxomatous or gelatinous 
change in others (Kyle). 

The tissue thus degenerated becomes pendulous and in most instances 
pedunculated. Such a tumor is known as a polypus. 

Other causes of hype plastic inflammation of the nasal mucous mem- 
brane, especially in the region of the middle turbinal, may eventuate 
in nasal polypi. If, for instance, a 

foreign body is lodged in the nasal fig. i84 

chamber for a long time, or any 
other continued source of irritation 
is present, it may result in nasal 
polypi. Some writers claim that 
the suction of the inspiratory current 
of air produces the tumors. Kyle 
has pointed out that the ingoing cur- 
rent of air exerts as much pressure 
as it does suction. As a matter of 
fact, the presence or absence of 
suction depends largely upon the 
location of the obstructive lesion of 
the septum in relation to the polypi. 
If the polypus is posterior to the ob- 
structive lesion, it is subject to suc- 
tion from the rarefied or negative 
air pressure posterior to the ob- 
struction. If there is no anterior 
nasal obstruction, the polypi are 
subjected to pressure rather than to 
suction. Suction may have some- 
thing to do with the formation of 
polypi in some cases, but it is not 
probable that it is often or ever the 
sole cause. 

Pathology. — While polypi are usually called myxomata, they are, 
as a rule, fibromyxomata. Pure myxoma is rare, and when found 
consists of an epithelium-covered connective-tissue sac, which contains 
a mucoid fluid, some bipolar spindle cells, and a fine network of con- 
nective tissue. The fibromyxoma, the usual type, is much richer in 
connective tissue, and less so in mucoid fluid. The tumors are sup- 
plied with bloodvessels and nerve filaments which do not penetrate the 
substance of the tumor, but are limited to the mucous membrane covering 
the tumor. They contain plasma cells, which stain with^polydrome, 




(a) The apparently open nostril, only open 
in its inferior portion. (6) The obstruction 
in tlie upper portion interfering with drain- 
age and ventilation of the sinuses, hence it 
gives rise to sinuitis, and later to polypi, 
(c) Nasal passage obstructed in its lower por- 
tion, (d) Open in the upper portion, hence 
drainage and ventilation of the sinuses are 
good; sinuitis and polypi absent, (f) Polypus 
on the apparently open side, but in reality 
on the side whei-e there is an obstruction in 
upper or sinus portion of tlie nose. 



256 



THE XOSE AXD ACCESSORY SIX USES 



inethyk'iu' blue, and eosin. Robert Levy reports a case of multiple 
cystic p()lyj)us richly supplied with bloodvessels, as shown in Fig. 185 

Symptoms. — The symptoms of nasal polypi are often complex 
on account of the nasal obstruction (middle turbinal region) and the 
associated nasal and sinus inflammation which usually co-exist. 

The symptoms referable to the polypi are largely dependent upon its 
location, size, and the amount of obstruction it produces. If it is pedun- 
culated, and hangs into the lower portion of the nose, it gives rise to 
the sensation of a movable foreign body in the nose. The patient can 
sniff and blow it back and forth in the nose at will. If it is sessile, it 
cannot be thus moved, but causes a feeling of 
Fig. 185 tightness or of fulness across the bridge of 

H the nose. The voice has the nasal twang 

■ in proportion to the obstruction produced 

I by it. The voice is often muffled, owing to 

I the almost total loss of nasal resonance. 

ak^^f Upon examination a grayish semitrans- 

BT / lucent tumor is seen hanging in the middle 

^j^^k^l meatus of the nose. If it is pedunculated, 

it may move with the inspiratory and ex- 
piratory currents of air. Probe pressure 
shows a soft and yielding mass freely 
movable in the nasal chamber. They 
may be single or multiple, but are more 
often multiple. H. W. Loeb reports a 
case from which he removed 308 polypi 
at one sitting. They vary in size from a 
pinpoint to such proportions as to extrude 
from the nose. 

Various reflex symptoms, as cough and 
asthma, may be caused by polypi. I have 
seen cases in which the cough or asthma 
was so persistent as to compel the patient 
to sleep all night with the head on the 
table for three months at a time, who were 
relieved by the removal of the polypi and 
the total exenteration of the ethmoidal cells. 
The external signs of nasal polypi are not always present excepting 
the inclination to keep the lips parted, so as to complement the nasal 
with the mouth breathing. In other cases the tumors are of such 
aggregate magnitude as to broaden the bridge of the nose. 

The sense of smell may be impaired or lost, owing to the closure of 
the olfactory fissure. The pharynx may be dry on account of the loss 
of the nasal respiratory functions, or from the thick, tenacious mucopus 
discharging into it. 

Caries and necrosis of the bone of the middle turbinal and of the eth- 
moidal cells may be demonstrated in some cases by the use of a heavy 
l)lunt-])<)iutcd pr()l)e. A small probe should not be used, as it might 




A polypus of the cyst adenoma 
type removed from the nose. Four 
cm. long, 2. .5 cm. wide, 1.25 cm. 
thick, weight 8 grams, color pinki.sh 
white, solid and elastic. The sec- 
tion shows numerous cavities filled 
with colloid and caseous material. 
Some of the cysts are lined with 
ciliated epithelium; others have a 
degenerated columnar cubical or 
flattened epitlielium, and in some 
the epithelium is entirely lost. 
Some areas are infiltrated with 
inflammatory round cells. (Robert 
Levy's specimen.) 



MYXOMA; NASAL POLYPUS 257 

readily pass through the degenerated mucosa and lead to a mistaken 
conclusion as to the condition present. The probe should be gently 
passed over the mucous membrane of the middle turbinal and along the 
lip of the hiatus semilunaris (uncinate process), as these are the most 
common sites of nasal polypi. They also grow from above the middle 
turbinal from the ostei of the posterior ethmoidal cells. 

The symptoms arising from the associated sinus disease are headache, 
dizziness, especially upon stooping or sudden jarring, irritability of the 
eyes upon prolonged reading, or even of unilateral blindness. (See 
Sinus Diseases.) 

Prognosis. — The prognosis of nasal polypi is good if they are 
removed, and the preexisting sinus and nasal disease causing them is 
also remedied. In those cases in v^hich the cause is a slight nasal 
inflammation the removal of the polypi followed by cauterization of 
their points of attachment will effect a cure. If the polypi are removed 
and the cauterization is neglected they are liable to recur. In those 
cases due to marked catarrhal or suppurative sinus inflammation a cure 
may necessitate not only the removal of the polypi, but the exenteration 
of the ethmoidal sinuses also. If caries of the bone is present the oper- 
ative procedure should include it as well as the polypi. 

Treatment. — In view of the marked tendency to recurrence the 
treatment is not as simple as is ordinarily supposed. The average 
practitioner regards his duty as being performed when he removes 
the growth, or growths, and establishes a fair degree of nasal respiration. 
The aim should be, however, to not only remove the growths, but to 
remove the tissue from which it springs, and to remove the diseased 
process (sinuitis), which is often the cause of it. Whether or not bony 
necrosis is always present, clinical experience teaches that polypi are 
much less apt to return if a portion of the periosteum and bone from 
which they spring is removed with the snare, curette, or biting forceps. 
The use of the galvanocautery or fused chromic acid upon the stumps 
of the polypi effectually prevents their recurrence in some sub- 
jects. 

The surgeon should ascertain as nearly as possible the points from 
which they spring, so that he may determine the difficulties likely to be 
encountered in the operation, and to enable him to formulate a correct 
prognosis if the extension of the operation is refused by the patient. 

I. Surgical Classification. — If polypi spring from the free border of the 
middle turbinatedbody their removal and after-treatment arecomparatively 
sim])le. In this location it is not difficult to engage the snare around 
the growth in such a way as to also include a portion of the middle turbinal 
from which it springs, though it may be removed with Holmes' scissors. 
Thus in a single operation it is sometimes possible to eradicate both the 
growth and its point of attachment. 

II. If they have their origin from above the middle turbinated body 
there is a strong probability that they come from the posterior ethmoidal 
cells. Here the treatment is much more complicated. It may become 
necessary to remove all, or a large part, of the middle turbinated body, 

17' 



258 THE NOSE AND ACCESSORY SINUSES 

(Figs. 170 and 171), and to exenterate the ethmoidal cells. After this is 
done the case may require occasional attention for several weeks. " 

III. When they have their origin in and around the hiatus semi- 
lunaris, either the maxillary, anterior ethmoidal, or the frontal sinus 
may be the seat of infection, and it may be necessary to perform a radical 
operation upon them to effect a cure. 

IV. In other cases they spring from the anterior ethmoidal cells, in 
which event the anterior ethmoidal cells and frontal sinus may be seri- 
ously involved. 

It is evident, therefore, that the simple removal of the polypi, or myxo- 
matous growths, does not constitute the whole duty of the attending 
surgeon. Such treatment is usually only palliative and temporary. 
The presence of polypi should be regarded as an indication that hyper- 
plasia of the mucous membrane and bone, and suppurative sinuitis are 
present. The same principles of treatment outlined for suppurations 
of the middle ear apply with equal force here. They are, briefly, (1) 
to establish free drainage; (2) to remove the morbid material; and (3) 
to maintain asepsis of the parts while healing is in progress. 

Operative Technique. — I. Polypi spmiging from the free border of 
the middle turbinated body are perhaps the most easily and successfully 
treated of the" types enumerated above. They are accessible and are 
attended by less involvement of the deeper tissues than in either of the 
other locations. The method of procedure is as follows : 

(a) Wash the nasal cavity with a warm antiseptic spray and apply 
adrenalin and a 4 per cent, solution of cocaine. This is best applied on 
a thin pledget of cotton saturated with the solution and introduced with 
an applicator and adjusted over the operative field. The cocaine should 
be left in position for about seven minutes. 

(6) Carefully inspect the polypus by the aid of reflected light, and deter- 
mine as nearly as possible its point of attachment. Having determined 
that it springs from the free border of the middle turbinated body, the 
next step is to examine for evidences of other diseased processes. 

(c) With a large blunt probe the point of attachment and neighboring 
parts should be examined for bare, rough bone. If a small probe is 
used, it may penetrate the unbroken tissue and thus come into contact 
with bony tissue. It is quite important, therefore, that a large one be 
used. It is not always possible to detect denuded bone, but if the 
examination is made in every case it will often be found where it is 
not otherwise suspected. 

{d) The wire loop of the snare should now be introduced, so as to 
encircle the pendant tumor. It should be introduced so that both sides 
of it are against the septum, the lower portion of the loop being on a 
level with or lower than the inferior portion of the polypus. It should 
then be turned so that its inferior part passes outward under the poly- 
pus, and then in an upward direction until the polypus is encircled. The 
procedure is often facilitated if the loop is also moved slightly in a for- 
ward and backward direction while engaging the polypus. 

(e) Care should be exercised to carry the loop so as to include the 



I 



MYXOMA: NASAL POLYPUS 



259 



point of attachment and a portion of the middle turbinated body if 
possible. If the growth is on the anterior portion of the turbinal it is 
usually easy to include the anterior third of it. The loop passes back- 
ward under and on either side of the turbinal, while the cannula (Fig. 186) 
is firmly placed in the notch formed by the anterior attachment of the 
turbinal and the anterior wall of the nose. 

(/) Firm pressure of the cannula into the notch being maintained, the 
loop is tightened until the tissues are engaged. It is still further tightened 
until the anterior portion of the turbinal, to which the growth is attached, 
is severed. 

(g) With a blunt probe the wounded surface is examined for evidences 
of carious or necrotic bone. 

(h) If softened or necrotic bone is found it should be removed by 
curettement. 

(i) If none of the middle turbinated body is removed the fibrous base 
of the polypus should be cauterized at the next sitting, or three or four 
days later. 




Removing a polypus and anterior end of the middle turbinal with a snare. 



(_/) The after-treatment should consist of the use of warm antiseptic 
douches or sprays and the insuflflation of bismuth-iodine powder. If the 
douche is used, the Birmingham nasal douche is preferable to any of the 
pressure or fountain douches, as they are apt to force the solution into 
the middle ear and excite severe inflammation. The douche should be 
used twice daily. 

II. When the polypi have their attachment above the middle turbinated 
body they usually spring from the ethmoidal cells, and the treatment is 
correspondingly more difficult. One may be able to remove a portion of 
the growths, but it is difficult to reach their points of attachment. It 
therefore becomes necessary to remove the anterior half or all of the 
turbinated body. This is not objectionable, as the ethmoid cells con- 
tained therein and those in the body of the ethmoid bone are probably 
more or less diseased. If necrotic bone is present it should be removed 
by curettement. In cases of this class my method of procedure is some- 
what as follows: 



2G0 THE NOSE AXD ACCESSORY^ SINUSES 

(a) The })relirainary preparations are the same as m the preceding 
paragraph I. 

(6) The polypi are removed as completely as possible with the snare, 
so as to clear the view of the operative field. 

The operation may stop here and the case be watched for further 
developments before adoptmg other surgical procedures in the middle 
turbinal and ethmoid regions. 

(c) The stump of the polypus may be cauterized with chromic acid 
fused on the point of an applicator or with the electrocautery. The appli- 
cator may be curved so as to pass above the middle turbinated body. 
The curve should be made in the probe before the acid is fused on its 
point, as it should be used at once before the water of crystallization is 
reabsorbed. 

(d) If after repeated removals the polypi persist, it will be necessary 
to remove a portion or all of the middle turbinated body in order to 
establish free drainage of the affected ethmoidal cells and to remove the 
polypi springing from them (Figs. 170 and 171). 

{e) The subsequent treatment consists of cleansing lotions and such 
other procedures as may become necessary in the course of the case. 
It may be necessary to perform repeated operations in order to eradicate 
the diseased process in the ethmoidal cells, or to secure the complete 
exenteration of the cells. The complete exenteration of the ethmoidal 
cells may be done at once if the surgeon is sure they are extensively 
involved. 

III. If the polypi spring from the hiatus semilunaris or infundibulum 
it may become necessary to open the maxillary antrum, as it may also 
be the seat of similar growths. 

The mode of procedure is somewhat the same as in the first type in 
so far as the nasal operations are concerned; that is, the growths 
should be removed with the cold^wire snare and their bases cauterized. 
If upon further observation the antrum is found to be aft'ected, the 
Cald well-Luc or Denker operation should be performed. (See pp. 223 
to 225.) 

IV. When the polypus arises from the border of the hiatus semilunaris 
or mouth of the infundibulum, there is probably an involvement of the 
anterior ethmoidal and the frontal sinuses in addition to the anterior 
disease. The treatment required is much like that described in I, in 
so far as the removal of the polypus is concerned. Subsequently it may 
become necessary to remove the anterior third of the middle turbinated 
body by the method described in II, or this portion of the turbinal 
may be successfully removed with the snare by keeping the cannula 
firmly fixed in the notch formed by the anterior attachment of the 
middle turbinated body and the outer wall of the nose, the loop being 
on either side of and beneath the turbinated body. 

i\fter this is done the diseased area is exposed to further examination, 
and, if need be, to more extensive operation by curettement. In other 
words, the obstructions within the "vicious circle" should be obliterated. 

V. "When the polypi spring from the superior meatus, the problem 



MYXOMA; NASAL POLYPUS 261 

involved is sometimes quite complex and perplexing. The posterior 
ethmoidal and sphenoidal cells maybe involved, necessitating their com- 
plete exposure by anterior rhinoscopy. To do this it is ordinarily neces- 
sary to remove the entire middle turbinated body, as described on 
pages 231 and 232. 

No arbitrary rules can be laid dowii in a text-book for the guidance 
of the surgeon. He must study the facts in each case, and arrive at a 
conclusion as to the best course to pursue. The foregoing operations 
are sometimes advisable if it is hoped to effect a permanent cure of the 
nasal polypi. These operations are usually only described in connection 
with the subject of empyema of the nasal accessory sinuses. I have 
described them in connection with polypi in order to emphasize the signi- 
ficance and importance of these growths, as pointing to conditions much 
more important than the polypi themselves. While in some cases it may 
not be shown that the polypi have much significance, nevertheless, in 
my experience, the more nearly I have treated polypi as though necrosis 
and suppuration were associated with them, the more satisfactory have 
been my results. 

For timid patients non-surgical treatment may be recommended, 
as the injection of a saturated solution of the sulphate of zinc, or a solu- 
tion of tannic acid into the substance of the polypi. I have occasionally 
used tannic acid with satisfactory results. A few minims should be 
injected with a hypodermic syringe into the body of the tumor. Within 
two or three days it shrinks and sloughs away. In the aged or the infirm 
it is usually inadvisable to recommend measures more radical than 
the simple removal of the polypi, as the danger from shock and acute 
infection is greatly increased in these subjects. 

Papilloma. — Papilloma of the nose is rare, but when it occurs it appears 
as a corrugated red tumorous mass growing either from the inner or 
inferior surface of the inferior turbinated body, the septum, or the poste- 
rior end of the inferior turbinated body. The subjective symptoms are 
those of a partial nasal stenosis, the patient often only consulting the 
physician on account of nasal "catarrh." 

Treatment. — The treatment consists in the thorough removal of the 
growth with a snare or nasal scissors. The growth of the surrounding 
tissues should be anesthetized by the local application of a 5 to 10 per 
cent, solution of cocaine, after which the tumor is excised. After the 
bleeding has ceased the wounded surface should be mopped dry and 
cauterized with the galvanocautery. This is done to prevent a recur- 
rence of the growth. Wlien papilloma recurs in a patient forty or more 
years of age, the possibility of carcinoma should be suspected. 

Fibroma. — Fibroma of the nose is characterized by the presence of a 
dense fibrous growth containing bloodvessels and no mucous glands, 
with slowly increasing nasal obstruction. The growths vary in size, are 
smooth and pale pink in color. They are firm to the touch or probe 
pressure, though not so dense as bone or cartilage. They may be sessile 
or pedunculated (Fig. 187). If pedunculated, they are movable like a 
poly])Us, tliough tluM'r consistency is quite dilfcrcnt. 



262 



THE NOSE AND ACCESSORY SINUSES 



They are usually attached to the septum, floor of the nose, or to the 
turbinated bodies. They sometimes have multiple attachments, owing 
to the inflammatory reaction excited by their presence. 

Treatment. — The treatment consists in their complete removal with 
a snare, cutting forceps, or, in extreme cases, the resection of the superior 
maxilla may be necessary. In those cases wherein the tumor is pedun- 
culated and comparatively small the removal with the cold-wire snare 
or the author's turbinotome is the easiest and best method to pursue. 

When the growth is sessile and large it may be removed piecemeal 
with cutting forceps, or at least so much of it that the snare can be passed 
over the balance. This procedure may be done under cocaine anesthesia. 
When the growth is so large that it invades 
i"i'= i**" the surrounding structures of the nose, and ex- 

tensive adhesions are present, it may become 
necessary to resort to a temporary resection of 
the superior maxilla to eradicate it. 

The operation as given in Surgical Tech- 
nique, by Drs. von Esmarch and E. Kowalzig, 
is as follows: Osteoplastic, or temporary, 
resection of the upper jaw (von Langenbeck, 
1861) is performed for the removal of non- 
malignant fibrous or. cavernous tumors which 
originate from the base of the skull, fill the 
nasal part of the pharynx (nasopharyngeal 
space) and force themselves into the max- 
illary sinus, or through the sphenomaxillary 
fossa into the temporal fossa (retromaxillary 
tumors). 

By reflecting a portion of the upper jaw^ 
upward, which has been sawed through, but 
which remains in connection with the soft 
parts, the tumor is completely exposed, so that 
it can be cut off from the base of the skull with 
a knife or scissors; this portion of the upper 
jaw is then replaced and the skin is sutured 
over it. 

Von Langenbeck proceeds as follows: 1. An 
external incision is made down to the bone in the form of a curve from the 
external angle of the nostril to the middle of the zygomatic arch (Fig. 188). 

2. Separation of the insertion of the masseter muscle from the lower 
margin of the malar bone division of the buccal fascia. 

3. After the lower jaw has been pressed do^^mward by a gag inserted 
at the angle of the mouth on the healthy side the right index finger is 
forced into the sphenomaxillary fossa between the tumor and the upper 
jaw and then through the distended sphenopalatine foramen as far as the 
nares; along the finger an elevator is carried, and on it a fine metacarpal 
saw is introduced into the pharynx. The left index finger, introduced 
from the mouth into the pharynx, catches the point of the saw. 




Fibromyxoma removed from 
tlie epipharynx. Actual size. 
(Specimen kindly loaned by A. 
G. Wippern.) 



i.«l 



MYXOMA: NASAL POLYPUS 



263 



4. Horizontal division (by sawing) of the upper jaw above the alveolar 
process as far as and into the pyriform aperture (Fig. 188). In operations 
on the right upper jaw, the left index finger is forced into the maxillary 
fossa, and the operator saws toward it from the nasal passage. 

5. Make the external incision down to the bone in the form of a curve 
from the root of the nose along the lower orbital margin, meeting the 
first skin incision at the zygomatic arch (Fig. 188). 

6. After the external lower angle of the orbit and the angle between 
the temporal and the frontal process of the malar bone have been freed 
from the soft parts the zygomatic arch is sawed through in the middle 
from within outward (Fig. 188); next, the frontal process of the malar 



Fig. 188 





Von Langenbeck's operation for the temporary excision of the superior maxilla, a b (large 
figure), the external skin incision; c, the zygomatic arch is first sawed through within outward; a, 
next, the frontal process of the malar bone is sawed with a metacarpal saw as far as and into the 
inferior orbital fissure, the orbital plate of the inferior maxilla as far as the lacrymal bone closely 
below the lacrymal fossa, and, finally, the middle of the nasal process of the superior maxilla as 
far as the nasal bones are divided. The contents of the lacrymal canal should be carefully 
guarded from, injury, b (small figure), horizontal division, with a saw, of the superior maxilla 
above the alveolar process as far as and into the pyriform aperture. 



bone as far as and into the inferior orbital fissure, the orbital plate of 
the upper jaw as far as the lacrymal bone closely below the lacrymal 
fossa, and, finally, the middle of the nasal process of the upper jaw as 
far as the nasal bone are divided with a metacarpal saw, protecting the 
organs which constitute the lacrymal duct. 

7. By means of an elevator inserted under the malar bone the excised 
piece of the upper jaw is lifted up toward the medium line, like the lid 
of a box. The sutural connection between the nasal bone and the upper 
jaw, in most cases, breaks during the maneuver. 

8. With a broad elevator the tumor, now laid bare, is lifted out of the 
sphenomaxillary fossa, and the base is detached from the under surface 
of the skull with a l<nife, scissors, or thermocautery. Finally, the 



264 THE NOSE AND ACCESSORY' SINUSES 

resected portion of the upper jaw is replaced in its former position and 
the wound of the skin is closed by means of careful suturing. 

For the better protection of the branches of the facial nerve, O. ^Yeber 
placed the nutritive bridge of the upper jaw, which must be turned up, 
externally upon the zygomatic arch, and by nicking it on the line of its 
suture with the zygomatic process of the temporal bone, he turns the 
zygomatic arch over in an outward direction. The external incision 
has already been described. The saw incisions are in other respects the 
same as in the preceding method (Fig. 188). 

Adenoma. — Adenoma bleeds so readily upon examination with a 
probe that sarcoma is at once suggested. A microscopic examination, 
however, reveals the true character of the growth. They grow from 
the septum or the ethmoidal region and produce rapidly increasing nasal 
stenosis. Adenoma, like polypi and papilloma, has a strong tendency 
to recur unless thoroughly removed. It consists of a simple hyperplasia 
of gland structure having its type in the acinous or tubular glands. It 
also has a tendency to malignant degeneration. 

Treatment. — The treatment should consist in the total removal of the 
tumor. In order to ensure this, its base should be cauterized or curetted. 
The bleeding attending the removal of adenomata is considerable, but may 
be readily controlled by a nasal tampon of sterile gauze. It is bad prac- 
tice to tampon the nose, as it is a septic field, and when it becomes neces- 
sary to do so, it is advantageous to moisten the gauze with the compound 
tincture of benzoin to prevent decomposition of the secretions and 
saprophytic absorption . 

Lymphoma. — Lymphoma of the hose is characterized by a smooth 
tumorous mass, pinkish red in color, and less dense in consistency than 
fibroma. It is not common and requires a microscopic examination 
to make a positive diagnosis. The treatment is the same as for polypus 
and fibroma. 

Angioma. — Angioma of the nose is rare (Kahn), and consists of a 
distention of existing bloodvessels rather than of new-formed ones. 
According to D. Braden Kyle the distention is due to changes in the 
bloodvessel walls from deficient nutrition rather than to mere congestion. 

Symptoms. — The symptoms are those of more or less nasal obstruction, 
epistaxis, and a reducible and pulsating tumor. The nasal obstruction 
is proportionate to the size of the growth. Pressure upon the growth 
materially reduces its size. The pulsation is more pronounced when 
the tumor is attached to a large artery. If the tumor is attached to a 
vein, the pulsation is much less and the color is blue, whereas if it is 
connected with both vein and artery the color will be a dark red. 

Treatment. — The treatment consists in the strangulation at the base 
of the tumor. The object of the strangulation is to cause closure of the 
bloodvessels supplying the tumor. If the strangulation is performed too 
quickly the vessels are not closed and hemorrhage from their severed 
ends results; by gradually tightening the wire loop the vessels close and 
bleeding does not follow. 

The galvanocautery loop is also well adapted for the removal of these 



MYXOMA; NASAL POLYPUS 265 

growths, when easily accessible and pedunculated, as it sears over the 
ends of the vessels and prevents subsequent hemorrhage. When the 
grow^th is sessile silk ligatures may be passed through it and tied, thus 
strangulating a portion with each ligature. Cocaine anesthesia is all 
that is necessary for either of the procedures. 

Osteoma. — Osteoma^ of the nose and the accessory sinuses is rare. 
It may occur in any of the accessory sinuses, but is more common in the 
frontal. It may invade the nasal and orbital cavities when growing 
from the sinuses. It sometimes springs from the inferior turbinated 
bone and occludes the nasal chambers. Cases have been reported 
having their origin from the nasal process of the superior maxilla. 

Pathology. — Osteoma is usually composed of dense, compact, cancellous, 
horny tissue of congenital or postnatal matrix of osteoclasts, and usually 
arises from the periosteum, though it may arise from the medullary 
portion of the bone. Some are soft and spongy, with a dense capsule 
of bone, while others are dense throughout their substance. The spongy 
type occurs most frequently. They are in some instances pedunculated, 
the pedicle being composed of either spongy bone or soft connective 
tissue and mucous membrane. The cases seen clinically vary in size 
from a small walnut to a goose egg. 

Symptoms. — As the nasal chambers are usually invaded, nasal obstruc- 
tion is a prominent symptom The growth of the tumor externally 
produces more or less marked deformity, and in some instances the re- 
semblance to horns is so great that the cases are referred to as "horned 
men." In some instances they present the "frog-face" type of counte- 
nance, especially when both sides of the nose are involved in the region of 
the infra-orbital ridge, as in Dr. Stein's case. Palpation of the tumor, 
whether intra- or extranasally, yields a sense of bony hardness. The 
lacrymal duct may be occluded. The mucous membrane covering the 
tumor is usually pale, thin, and not eroded. Transillumination of the 
maxillary sinus may show^ obstruction to the rays of light. If constant 
mouth breathing is present it gives rise to epipharyngeal catarrh. In 
Stein's case there was inability to rotate the left eye inward. There 
was external divergence of two lines, pupil widely dilated and fixed, not 
responding to either light or accommodation. The fundus was normal. 

Diagnosis. — The diagnosis is largely based upon the microscopic 
examination of the tissue. 

Treatment. — In those cases of syphilitic origin the iodides are of value. 
The removal of the bony growths is usually the best treatment. The 
technique of the operation varies with each case. In the 23 cases growing 
from the frontal sinus reported by Boenhaupt, 11 communicated with 
the cranial cavity. It is obvious, therefore, that osteoma of this region is 
most serious from a clinical and surgical point of view. 

In the removal of osteoma attempt to find a pedicle, or, failing in this, 
enucleate the tumor rather than attempt to chisel or drill into its sub- 
stance, as it is often so dense as to resist these instruments. 

' I am indebted to Dr. Otto Stein's paper on "Symmetrical Osteoma of tlie Nose" for most of 
llio data (in this suhjoct. 



266 THE NOSE AND ACCESSORY SINUSES 

Lipoma. — lipoma of the nose may te external or internal, and is 
usually pendulous. When external it usually affects the alse of the 
nose. The case illustrated involves the tip of the nose (Fig. 189). 




Lipoma of the tip of the nose. (Pynchon's case.) 



MALIGNANT NEOPLASMS OF THE NOSE. 

Carcinoma. — Carcinoma of the nose is more rare than sarcoma, and 
usually begins in the anterior portion of the nasal structures, as the 
greatest irritation occurs at this point. 

Diagnosis. — The diagnosis is based upon (a) the presence of an in- 
tense irregular lancinating pain; (6) a mucopurulent secretion, which 
if ulceration is present is admixed with blood; (c) the characteristic 
ozena or stench of cancer; (d) nasal stenosis more or less marked 
according to the stage in which the disease is observed; (e) impairment of 
vision if the ethmoid cells are involved; (/) ulceration of the growth if 
in an advanced stage; and (g) cachexia, (h) In addition to the foregoing 



MALIGNANT NEOPLASMS OF THE NOSE 267 

clinical symptoms it is usually necessary to remove a portion of the 
growth for microscopic examination. D. Braden Kyle properly calls 
attention to the necessity of observing two precautions in securing the 
specimen, namely: " (1) That there should be as little laceration and 
irritation of the parts as possible; (2) that the portion removed should 
not involve directly the ulcerated area, which will contain inflammatory 
embryonic connective tissue. As pointed out by J. Bland Sutton, this 
cannot be differentiated from sarcoma or from a simple inflammatory 
process with ulceration. If, however, the specimen is taken early, 
before ulceration has occurred, this source of error may be obviated." 

Prognosis. — ^The prognosis is always grave. 

Treatment. — ^The surgical treatment of carcinoma of the nose, except 
in the very early stage, is contra-indicated. 

The palliative treatment consists in the local application of orthoform 
powder to ease pain, and local applications of dilute hydrochloric acid 
and formalin to the ulcerated areas. 

Sarcoma. — Sarcoma of the nose is of slow growth, and is less malig- 
nant than sarcoma in other parts of the body. Unlike carcinoma it 
occurs most often before the fortieth year of life, and is not uncommon 
in infancy and childhood. 

Diagnosis. — The diagnosis is based upon (a) progressive nasal stenosis; 
(b) a mucopurulent nasal secretion, which, in the advanced stage, 
becomes sanguinolent; (c) more or less slight pain in strong contrast 
to the intense pain in carcinoma, (d) The age of the patient, if below 
forty years, is also of diagnostic significance, though carcinoma occa- 
sionally occurs before this age; (e) finally, the diagnosis must be made 
by submitting a specimen of the growth to microscopic examination. 

Prognosis. — The prognosis is grave, though not so grave as carci- 
noma. When operated early there is a fair chance of recovery. In 
one of my cases operated by Ollier's method (Fig. 190) there has been 
no recurrence of the sarcoma after five years. 

Treatment. — The treatment in the early stage is surgical, especially in 
view of the slighter malignancy of nasal sarcoma. The growth may 
be removed with a curette, or galvanocautery through the nasal 
orifices, or, if extensive, an external operation may be required. 

Ollier's Operation. This operation is performed under general anes- 
thesia, with the head of the patient hanging over the end of the table 
in Rose's position. Postnasal tampons should be introduced to pre- 
vent the blood escaping into the epipharynx and larynx. An incision 
extending from the left ala of the nose, upward over the bridge of the 
nose, and thence downward to the right ala of the nose, should be 
made through the cutaneous tissue (Fig. 190). A Gigli saw should then 
be placed at the bridge of the nose and all the bony structures along the 
cutaneous incision severed. 

The nose, thus temporarily resected, is then turned downward over 
the mouth. This having been done, the growth should be enucleated 
by blunt dissection, if possible, or if this cannot be done it should be 
removed by (lull nircttage. A sharp curette should not lie used, as it 



268 THE NOSE AXD ACCESSORY SIXUSES 

leaves the lymphatic vessels open and favors extension bv metastasis 
and septic infection. The hemorrhage may be consideral)le, hence the 
postnasal tampons introduced before beginning the operation serve as 
bases against which strij)s of gauze may be packed to check it. 

In my case, illustrated in Fig. 190, the hemorrhage was very profuse 
and necessitated the use of normal salt enemata. The transfusion of 
normal salt solution would have been better, but as arrangements had 
not been made for it the enemata were substituted. This patient was 
thirteen years old when I first saw her, and was fourteen when I per- 
formed the Oilier operation. She is now nineteen years of age, and is 




Ollier's incision for exposing the nasal cavities for operative purposes. 

free from the growth. Bony sequestra have been removed from time 
to time, and but little ozena is present. The cure is apparently per- 
manent. 

Having removed the tumor the incision should be closed by sutures, 
and the tip of the nose raised into position and fixed with adhesive 
strips. The stitches should be removed on the fifth day. The nasal 
wound should be packed with gauze impregnated with bismuth or the 
compound tincture of benzoin, to prevent decomposition and sapro- 
phytic infection. The intranasal dressing should lie removed and 
renewed dailv. 



CHAPTER XIV. 

EPISTAXIS (NASAL HEMORRHAGE). RHINOSCLEROMA. 
FURUNCULOSIS. SCREW-WORMS. 

EPISTAXIS (NASAL HEMORRHAGE). 

Epistaxis is a nasal hemorrhage, that is, a bleeding from the interior 
of the nose. While the hemorrhage is usually from the anterior portion 
of the septum (90 per cent, according to Casselberry), it may occur from 
any portion of the nasal mucosa. The bleeding is not often serious in 
character, though several deaths have occurred therefrom. It is most 
serious in bleeders, or hemophiliacs, arteriosclerosis, valvular heart 
lesion (right side), sarcoma, and pressure on the veins of the neck by 
aneurysm, bronchocele, and intrathoracic tumors. 

Etiology. — (a) Anterior deflection of the septum is the predisposing 
cause of hemorrhage in a large majority of the cases. This portion 
of the septum is richly supplied with blood from the septal artery, a 
branch of the superior coronary, and is exposed to the ingoing current 
of air, which is often loaded with foreign particles. The air, further- 
more, dries the secretions on the anterior portion of the septum, 
especially if it is deflected in this location. The membrane is quite thin 
in this area, as anyone who has done a submucous resection of the 
septum can testify. Slight erosion of the mucosa readily gives rise, 
therefore, to nasal hemorrhage. 

(b) Catarrhal inflammation causes chronic hyperemia of the mucous 
membrane, hence the increased blood in the parts contributes to the 
epistaxis. 

(c) A number of febrile diseases are often attended by epistaxis. 
The diseases most commonly thus characterized are typhoid and diph- 
theria, though other infectious fevers are sometimes attended by nasal 
bleeding. " Black diphtheria," or hemorrhagic nasal diphtheria, is at- 
tended by a destructive degeneration of the nasal mucosa, submucous 
hemorrhage, and epistaxis. 

(d) The veins on the anterior portion of the septum are sometimes 
varicosed and give rise to hemorrhage. 

(c) Obstruction to the portal circulation may be attended by nasal 
hemorrhage. 

(/) Suppression of the menstrual flow and of a severe hemorrhoidal 
hemorrhage is sometimes attended by a vicarious nasal hemorrhage. 

{[/) Traumatic epistaxis may result from picking the nose with the 
finger nail or violently blowing it with a handkercliief. Intranasal 
surgery is frequently followed by severe nasal hemorrhage. This is 
especially true after operations upon the middle turbinal, the ethmoidal 



270 THE NOSE AND ACCESSORY SINUSES 

foils, and the swell bodies or erectile tissue of the inferior turbinated 
body. The middle turbinated and the ethmoidal cells receive a generous 
blood supply from the anterior and posterior ethmoid arteries (Fig. 3). 
External violence to the nose is often followed by epistaxis or the 
so-called "bloody nose." 

(h) A perforating ulcer of the septum frequently gives rise to* epis- 
taxis. The vessel walls are broken down in the destructive process, 
and the granulation tissue upon the border of the perforation bleeds 
easily upon slight provocation. 

(i) Certain constitutional diseases, as hemophilia, Bright's disease, 
purpura, scorbutus, chloremia, leukemia, and arteriosclerosis are char- 
acterized by nasal hemorrhage, for obvious reasons. S^'philis and tuber- 
culosis of the nose also give rise to epistaxis. 

(j) Sarcoma of the nose, like sarcoma elsewhere, is often attended 
by hemorrhage. 

Treatment The treatment of nasal hemorrhage in most cases is 
simple enough, as the local application of cocaine or of adrenalin readily 
stops it. In other cases, however, when the cause is a constitutional 
disease, a growth pressing on the veins of the neck, or when the trunk of 
one of the larger septal arteries, as the anterior ethmoidal, is severed in 
an intranasal operation, the bleeding is not so easily checked. 

The hemorrhage may usually be checked by one of the following 
procedures : 

1. Hot nasal irrigation is quite effective in many of the cases when 
the epistaxis is not due to some grave disease. The temperature of the 
water or normal salt solution should be as high as can be tolerated, or 
about 130°. 

2. Ice-water may also be injected into the nose with advantage in oper- 
ative hemorrhage while the patient is under an anesthetic. Only two or 
three injections of four ounces each should be used, as to use more might 
produce serious shock to the brain by sudden or excessive chilling. 
I have frequently resorted to this method of treatment at the close 
of nasal operations when the hemorrhage was profuse, with the most 
gratifying results. 

3. The local application of cocaine or adrenalin often checks the 
hemorrhage when it is of capillary origin. If blood clots are present, 
the nose should first be cleared. The adrenalin extract may be given 
internally for its hemostatic effects. 

4 Blood clots are sometimes allowed to remain in the nose, with the 
idea that they will finally check the hemorrhage. This procedure is 
based upon an erroneous idea. The blood clots only serve to shield 
the bleeding area from such local medicaments as may be used, thus 
hiding the bleeding point from view The bleeding usually continues 
beneath the clots, hence they should be thoroughly removed at once to 
expose the bleeding area to inspection and to make it possible to apply 
such local remedies as may be deemed necessary. 

5. Astringent remedies, as the nitrate of silver in 5 to 20 per cent, 
solutions, may be made from time to time in persistent oozing. 



RHINO SCLEROMA 271 

6. The application of the actual cautery has sometimes proved a 
speedy and efficient means of controlling the bleeding; a flat-pointed 
electrode should be used at a cherry-red heat for this purpose. 

7. Local pressure over the bleeding point for a few minutes will 
sometimes control the bleeding. 

8. Tampons in the nose should only be resorted to in those cases in 
which, the bleeding persists in spite of all other measures. Tampons 
in the nose as a general proposition should be avoided, as they are apt to 
give rise to conditions favorable to sepsis. The more completely the 
nasal chambers are packed with gauze the greater the danger Hence, 
a postnasal tampon followed by an anterior one is the most dangerous 
of all. Resort to this method of packing the nose in epistaxis should be 
avoided except in an extreme emergency. 

When the bleeding is from the anterior portion of the septum, and 
it becomes necessary to introduce a tampon, I would advise a Bernay 
tampon cut into the form of a nasal splint, as recommended by Simpson. 
It absorbs less of the secretions, and is easily introduced and removed 
without further injury to the diseased mucous membrane (Fig. 70). 



RHINOSCLEROMA. 

Synonyms. — ^The evidence seems to be almost convincing that a rare 
lesion described as chorditis, chronic hypertrophica inferior, and what 
is known as Stoerk's blennorrhea are identical with rhinoscleroma. 

Definition. — Rhinoscleroma is characterized by a cartilage-like hard- 
ness and nodular enlargement of the nose and other portions of the 
upper air passages. The affected tissues have no tendency to ulcerate 
or to inflammatory reaction, either in the growth or in the contiguous 
parts, although it frequently affects the other divisions of the respiratory 
tract. 

Etiology. — But little is known of the etiology of the disease beyond the 
fact that it is due to a specific microorganism, the bacillus of rhinoscle- 
roma, and that it is chiefly confined to Austria and southwestern Europe. 
About 800 cases have been reported, and of these, about 20 occurred in 
America, but the large majority of them were from Poland and Austria. 
It usually begins in youth, the greater number being observed between 
the ages of fourteen and forty-five. Sex seems to have no influence. 
Heredity seems to be a negative factor, though there is apparently a 
family predisposition to the disease. It is now generally regarded as a 
contagious disease. 

Bacteriology. — The hard, cartilage-like nodules affect the skin and the 
mucous membrane of the nose, pharynx, larynx, and trachea. It spreads 
with greater freedom in the mucosa than in the skin. The hard, nodular 
masses, or plaques, contain the encapsulated bacillus of rhinoscleroma, 
which is similar to Friedlander's bacillus, though the latter is not 
always encapsulated. The bacillus of rhinoscleroma is more rod- 
shaped, and stains by Gram's method, is motile, non-spore bearing, 



272 THE NOSE AND ACCESSORY SINUSES 

and aeroljic. It always has a capsule in culture, as well as in the tissues. 
It occurs singly and in pairs. Gelatin plates show yellowish-white 
granular bodies in two or three days. In gelatin tubes the growth 
appears along the needle track as a whitish granular line, with an almost 
hemispherical elevation on the surface. The growth in the tube has 
the appearance of a round-headed nail. When grown upon agar it 
appears as a dirty whitish moist layer on either side of the needle 
track. On potato the growth is creamy white. It grows rather rapidly 
at a temperature of 37° C. It is pathogenic for mice, guinea pigs, and 
rabbits 

Pathology. — The histological changes are inflammatory in character 
and usually begin on the nasal septum, trachea, or larynx. In rare in- 
stances the reverse course is pursued. The skin and mucous membrane of 
the nose assume a smooth nodular appearance of cartilage-like consistency, 
which pits little or none upon probe pressure. The parts are sensitive 
to the touch, but are otherwise free from pain. Kaposi has likened the 
external appearance of the nose to keloid. Goodale (Posey and Wright) 
gives the following description of the pathological changes : 

"In the nose and lar\mx the affected tissues are seen histologically 
to consist of certain typical elementary lesions. The substance of the 
swelling is composed of large plasma cells, irregularly distributed in all 
layers of the mucous membrane, and in the submucous tissue. They 
accompany the bloodvessels in the new portions of the growth. The 
plasma cells do not contribute directly to the hypertrophy, but it is 
possible that they become changed partly into spindle cells, and then 
give rise to the formation of new fibrillary tissue. Two forms of retro- 
grade metamorphosis occur in the plasma cells. These may be trans- 
formed into swollen, hydropic, so-called ^Mikulicz cells, or into hyaline 
degenerated cells, probably identical with the so-called Russell's fuchsino- 
philes, described under Colloid Degeneration. The hydropic cells lie 
close together, have a distinct contour and spongy cytoplasm dilated 
into large masses, in which there is a smaller mass within a faceted 
nucleus. In this stage one often sees from six to eight bacilli in the 
cells near the nucleus which lie always at regular distances. 

"This stage appears, however, to be rapidly finished, and when the 
cell membrane breaks, the fluid contents, together with some of the 
bacilli, find an exit and fill some of the nearest lymph spaces. These 
cells arc, liowever, intimately related to the direct action of the bacilli." 

Symptoms. — The changes in the external appearance of the nose, 
while presenting many of the characteristics of keloid, are, nevertheless, 
rather easily (lifferentiated from it by the w^iole symptom complex. 
The tissues at the tip of the nose l)ecome infiltrated, hard, and nodular. 
The nose broadens and becomes firmly fixed to the face. The tissues 
become more and more thickened, imtil the breathing is more or less 
occluded. The color of the skin varies from a red to a bluish or brown- 
ish red. The skin is traversed by small bloodvessels, and is usually 
slimy, though it may be finely wrinkled. The extension of the growth 
is rather slow, requiring several months to reach the epiphar^mx. The 



FURUNCULOSIS OF THE NOSE 273 

infiltration often interferes with the movement of the hps, the fauces, 
and the laryiix, and very rarely of the eyes and ears. There is no 
tendency to ulceration and discharge, or to edema and inflammation of 
contiguous parts. 

Laryngeal stenosis may give rise to serious or even fatal dyspnea, 
otherwise the disease does not materially affect the general health. 

Diagnosis. — Rhinoscleroma should be differentiated from syphilis, 
epithelioma, and keloid. The disease is exceedingly rare in this country, 
hence it is natural to infer that a suspected case is probably not rhino- 
scleroma, but that it is either syphilis, epithelioma, or keloid. This is 
not necessarily true, however, as 20 authentic cases have been reported. 
Rhinoscleroma presents a hard, nodular growth, usually beginning at 
the anterior end of the nose, spreading gradually to the deeper recesses 
of the respiratory tract, without pain, but some tenderness upon pressure, 
and without tendency to ulceration or inflammation of the surrounding 
tissues. In syphilis there is inflammation, while in epithelioma there is 
pain, ulceration, and discharge. In keloid the similarity is often so 
striking that it may be necessary to demonstrate the absence or 
presence of the germ of rhinoscleroma in order to make a differential 
diagnosis. 

Treatment. — Thus far the extirpation of the diseased tissue has been 
tried with a negative result as to the cure of the disease. The surgical 
extirpation of the diseased tissue has almost invariably been followed 
by recurrence. Tracheotomy should be performed when suffocation 
is imminent. Thiosinamin affords a ray of hope, as it appears (Glass) 
to soften the tissue, as it does in keloid. A reliable method of treatment 
has not been discovered. Freudenthal suggests the injection of Coley's 
fluid, as in sarcoma. The iodides and mercury have been tried with but 
little success. The rc-rays have been used by Emil Mayer with some 
apparent success, though it is probable that this mode of treatment will 
prove disappointing, as have all other methods of treatment. 

FURUNCULOSIS OF THE NOSE. 

Definition. — Furunculosis of the nose is a superficial abscess formation 
in any part of the nose, and does not differ materially from the same 
process in other parts of the body. 

Etiology. — The abscess is usually located on the anterior portion of 
the septum, i. e., that portion covered by skin, and is usually due to an 
injury, as from picking the nose. One or more may be present at a time 
or fjuickly succeed one another. The hair follicles of the vestibule offer 
favorable sites for their formation. If they recur frequently the 
cartilaginous septum becomes involved. Recurrences most commonly 
take place in the young or the middle aged, and especially in those with an 
impoverished state of the blood. The iiitVcd'ous fevers are often attended 
by nasfd furunculosis. 

Symptoms. — 'i'hcrc is more or less lln'obbiiig pain, swelling, I'cdness, 
and tenderness. The elevated areas chai-acteristic of boils may be .seen 
18 



274 THE XOSE AXD ACCESSORY SIXUSES 

upon inspection. Wlien they are well advanced, or, to use a vulgar 
expression, "ripe," the centre of the elevation is yellowish from the 
contained pus. The pain is often intense, on account of the closely 
attached and unyielding nature of the tissue composing the parts 

Treatment. — If seen early, before pus formation, the application of a 
50 per cent, solution of ichthyol or a 10 per cent, glycerin solution of 
carbolic acid on a pledget of cotton will often abort the process. If 
they have gone on to pus formation they shoidd be incised from 
within the nasal cavity with a sharp bistoury to avoid an external scar. 
After incision their cavities should be irrigated with warm boric acid 
solution and the tincture of iodine applied. 



PHLEGMONOUS RHINITIS. 

This is somewhat different from furunculosis, in that it is an abscess 
formation affecting the nasal mucous membrane. The condition is 
rare except as the result of an operation or other traumatism. (See 
Abscess of the Septum.) 



SCREW- WORMS IN THE NOSE. 

Screw- worms in the nose have been reported by ]M. A. Goldstein, 
Hal Foster, and J. S. Steele in most interesting and instructive articles, 
wherein it is shown that their invasion of the human being is not as rare 
as might be supposed. (See Foreign Bodies in the Ear.) 

The screw-worm fly is attracted by a foul-smelling discharge from the 
nose or the ear, and its presence in the nose need be but a moment for it 
to deposit its eggs. Dr. Steele narrates a case illustrative of this point. 
A railway engineer, while walking across the plaza of a Mexican city, 
inhaled a fly into one nostril, which he immediately blew out through the 
other. Twenty-four hours later fulness and pain between the eyes was 
noted, which increased for three days, when he came under observation. 
He was affected by specific rhinitis with necrosis of the nasal septum, 
which accounted for the fly being attracted to his nose. About one 
hundred worms were removed with the douche and forceps. Calomel 
was used by inhalation, which seemed to exterminate all that remained, 
as they gave rise to no further symptoms. 

Foster removed two himdred and seven worms from the nose of an 
old Irish woman who was subject to epileptic fits, during which she would 
fall to the ground. Following one of these seizures she noted an itching 
of the nasal mucosa, which was accompanied by headache and sneezing. 
She was told that she had hay fever, and large doses of quinine were 
administered. Two days later the nose began to bleed and to give forth 
a very offensive discharge. The eyes were closed from swelling of the 
subcutaneous tissue of the face, and she was in such discomfort that she 
was unable to sleep. 

Upon examination the nostrils were found to be entirely filled with 



FOREIGN BODIES IN THE NOSE 275 

worms. Inhalations of chloroform were administered, which rapidly 
rendered them lifeless, after which they were readily removed with 
forceps. The live worms clung with tenacity to the tissues when force 
was applied for their removal. There was great destruction of tissue, 
and the temperature was 102°. There was a bulging on the anterior 
part of the nose as a result of the penetration of the worms at this 
point. 

Goldstein's case was that of a farm laborer who slept outdoors in 
a hammock. He was affected with syphilitic rhinitis, which offered an 
ideal attraction to the Texas screw-worm fly. When examined the nose 
was found to be filled with the eggs of the fly, five hundred being removed 
with the curette. The curettage was thoroughly done, considerable 
tissue being removed along with the eggs. Forty-eight hours later there 
was excruciating pain in the nostrils, which were completely occluded. 
The skin over the frontal sinus was red and tightly drawn. On the 
sixth day there was swelling over the dorsum of the nose near its centre. 
This was incised and considerable pus was discharged. Several worms 
were subsequently removed through this opening. 

Chloroform is the most effective remedy, and may be administered by 
inhalation or in diluted solution with a syringe. Calomel fumigation 
is also of value, but does not act as quickly as chloroform. Steele's 
case shows that its effects were apparent after about four hours, whereas 
chloroform is effective within a few seconds or minutes. 



FOREIGN BODIES IN THE NOSE. 

Foreign bodies in the nose may be animate or inanimate. 

Animate or live objects, as the larvae of certain flies, commonly called 
maggots, are deposited in the nose in the form of eggs by the fly, and 
after a short period are hatched as larvae. They may burrow into the 
tissues, even to the point of making their exit through the skin. They 
may penetrate the wall of the nose in any direction, hence may enter the 
cranial cavity or the sinuses. 

The treatment of animate foreign bodies or larvae in the nose may be 
either medical or surgical. If the larvae are confined to the nasal 
chambers they may be removed by injecting a solution composed of 
equal parts of chloroform and water into the nose. While the solution 
causes pain it is nevertheless necessary to use it, as the larvae cannot be 
removed until they are killed, and chloroform accomplishes this end. 
If necessary the patient may be given a general anesthetic before inject- 
ing chloroform into the nose. After the injection of the chloroform into 
the nasal chambers the larvae may be easily removed with forceps or 
curette. (See Screw-worms in the Nose.) 

Inanimate foreign bodies include almost every kind of inert substance 
small enough to be introduced into the nose, and some that are too large 
to be introduced into the nose, at least through the nasal openings. One 
such case was under my care and gave the history of having received a 



270 THE XOSE AM) ACCESSORY SIXUSES 

wouiul thirty years previously from the explosion of a musket. The left 
eye was destroyed at the time. Upon removal of the foreign body it 
proved to be the breech pin of the musket which explodetl thirty years 
previously. The mass of iron, as large as the first joint of the thumb, 
still preserved its mechanical form, as the screw threads and the tubular 
space for the flash powder. The cap pin was also intact. In most in- 
stances the foreign body is volimtarily introduced by the patient. Young 
children have an inordinate desire to introduce such substances into their 
noses, hence most cases occur in young children. Idiots and the insane 
also delight in putting foreign substances into their noses. 

The treatment is generally easily accomplished through the anterior 
nasal opening without the use of a general anesthetic, though in many 
cases it W'ill be necessary to administer a general anesthetic. Forceps 
with good, grasping tips should be used to seize the foreign body and, 
after dislodging it, to remove it. 



J 



CHAPTER XV. 



THE SURGICAL CORRECTION OF EXTERNAL NASAL DEFORMITY. 



As each case is of necessity a law unto itself, it is impossible to describe 
operative procedures applicable to all types of deformed noses. Then, 
too, the patient's idea of nasal beauty varies to such an extent that 
his opinions, as to the cosmetic results, must be taken into consideration. 
I shall, therefore, only present a few suggestions as to the more common 
nasal deformities. 

The Aquiline or Hump Nose. — Occasionally the possessor of an 
aquiline nose, especially if the "hump" is quite prominent, is anxious 
to have the "hump" removed or reduced. This may be done by external 
incision, or subcutaneously through the nose. Preference should be 
given to the intranasal route, as 

it is not attended by a visible Fig. 191 

scar. I cannot conceive of a 
deformity of this kind that may 
not be removed via the nasal 
chambers. 

External Operation. — If, how- 
ever, an external incision is pre- 
ferred, it should be made in the 
median line of the nose, over the 
area of deformity- The skin and 
periosteum should then be raised 
on either side, exposing the prom- 
inent nasal bones (Fig. 191). 
The elevated flaps should be 
pulled aside by retractors in the 
hands of an assistant. The sur- 
geon should then carefully re- 
move enough of the projecting 
nasal bones to reduce the de- 
formity to the degree suggested by the patient. The skin and peri- 
osteal flaps should then be coaptated by adhesive strips and allowed 
to heal by first intention. Stitches should be avoided if possible, as they 
add to the prominence of the linear scar in the median line of the 
nose. The adhesive strips may be removed at the end of from 
three to five days. 

Intranasal Operation by the Author's Method. — This method of operating 
should usually be chosen, as it is not attended by an external scar. 




External operation for the removal of the 
"hirnip" from the nose. 



!78 



THE XOSE AXD ACCESSORY SIXUSES 



Technique. — (a) General anesthesia. 

(6) Thoroughly irrigate the nasal chambers with warm salt or boric acid 
solution, or otherwise clear the nose of the crusts, secretions, and bacteria. 

(c) Introduce a scalpel into one nasal chamber until its point reaches 
the lower border of the nasal bone, then make an incision through the 
nnicous membrane and pass the blade of the knife between the nasal 
bone and the skin covering it. 

Fig. 192 




The author's reverse cliisel for subcutaneous correction of nasal deformities 
Fig. 193 Fig. 194 





I'lc. 193. — Tlie author's method of removing the "hump" from an excessively aquiline nose. 
a, the deformed nasal bone; b, the author's reverse chisel reducing the "hump." 

Fig. 194. — The author's method of shortening a long, overhanging nose. The triangular piece 
of cartilage a is removed via the nostril and the gap closed by lifting the tip of the nose upward 
and securing it in place with adhesive straps applied externally. At the end of a week or ten 
days the straps are removed and union is complete. 

(d) Withdraw the knife and introduce a small elevator of the Freer 
ty})e and separate the skin from the anterior portions of both nasal bones. 

(c) Withdraw the elevator and introduce the author's draw chisel 
(Fig. 192), and with a downward and forward pull (parallel with the 
ridge of the nose) shave the anterior borders of the nasal bones until 
the hump is sufficiently reduced (Fig. 193). 



THE SURGICAL CORRECTION OF NASAL DEFORMITY 



279 



(/) Have the skin over the operative field gently massaged every three 
hours to prevent the deposit and organization of a plastic exudate over 
the bones previously reduced. Heat, or the leukodescent light applied 
over the nose, will also control the amount of inflammatory deposit. 

(g) Compression with a nasal pad and a roller bandage may be used 
instead of massage, heat, etc., if these modalities of treatment are not 
available. 

The Long or Drooping Nose.— This type of nose is occasionally 
seen. I have twice corrected the deformity. The method pursued by 
me has been the resection of a wedge- 
shaped piece of the nasal septum Fig. 195 
through the nasal orifice. 

Technique. — (a) Cocaine anesthesia 
as for the submucous resection of the 
septum. 

(6) Make two incisions through 
the entire thickness of the septum, 
as shown in Fig. 194. Connect the 
divergent ends of the incisions at the 
ridge of the nose by an intersecting 
incision, which should separate the 
cartilage from the skin of the nasal 
ridge. 

(c) Remove the triangular piece of 
cartilage with forceps. 

(d) Draw the whole end of the 
nose upward with strips of adhesive 
plaster, 

(e) At the end of from four to eight 
days remove the adhesive strips. 

After-treatment. — To prevent local 
infection and assure firm union of 

the septal wound, introduce pledgets of cotton saturated with a 10 
per cent, solution of ichthyol in glycerin every four hours for three days. 
The ichthyol is antiseptic and the glycerin promotes osmosis of serum 
from the bloodvessels and washes away any bacteria that chance to 
invade the region of the wound. 

Remarks. — When the nose is shortened in this way there is no redund- 
ancy of skin as it contracts until the normal tension is established. 

Paraffin Injection. — The use of paraffin is at the present time past the 
stage of experimentation, and is, in fact, a well-established procedure in 
surgery, especially in nasal work The principal use of paraffin is for 
the correction of congenital and acquired deformities. One of the 
principal locations for its use is the bridge of the nose for cosmetic pur- 
poses, that is, the characteristic saddle nose. The various locations and 
conditions where paraffin has been used about the ear, nose, and throat 
are as follows: 

1. Saddle noses, following trauma, syphilis, and cretinism. The case 




Congenital saddle nose due to cretinism. 



2,90 T^HE XnSK AXD ACCESSORY SIXUSES 

sliown ill Fig. ]*.).') was duo to cretinism The patient is a graduate 
of the High School of Chicago, and is an intelhgent young woman, 
twenty-four years old. 

2. Following operations on the frontal sinus (o correct the frontal 
deformity. 

3. To overcome the collapse of the alue nasi. 

4. Intranasal injections into the inferior turbinated body in atrophic 
rhinitis. 

5. Following resection of the superior maxillte to fill up the defect. 

0. Partial reconstruction of the inferior maxillne following necroses 
and resection for malignancy. 

7. Secondary repair of harelip, where there is great absence of the 
premaxillary bone. 

8. In the region of the postnasal space in cases of speech defect (rhino- 
lalia pata) attending the cleft palate operation or immovable palate. 

9. Following mastoid operations to fill up large retro-articular de- 
formities. 

The paraffin may be injected either hot or cold, depending upon the 
firmness of the paraffin required. The hot becomes the firmer after 
cooling, hence for the correction of a saddle nose the hot paraffin should 
be used. Cold paraffin should be used intranasally to build up the 
inferior turbinated body. 

The instrument required for this procedure is the paraffin syringe, 
(Fig. 196), wdiich may l^e used for either the hot or cold paraffin. 

The paraffin which is to be injected hot is kept in an ounce bottle, 
the cold in tubes, and is especially prepared to fit in the syringe 

Technique. — In case hot paraffin is to be used, place the bottle in boiling 
water until it liquefies, then fill the syringe with it. Turn tlie screw 
head from left to right until the paraffin comes out of the needle in the 
shape of a thread. Then introduce the needle into the cavity to be 
injected and continue to turn the piston slowly until the desired amount 
has been injected. In case the cold paraffin is used it is not necessary 
to first heat the paraffin, but simply use it in the semisolid form in which 
it comes, by the same process of turning the screw head until the desired 
amount has been injected. 

The opening caused by the introduction of the needle is sealed up by a 
small pledget of cotton moistened with collodion. Considerable bleeding 
from this point sometimes occurs, and pressure should be applied for a 
few minutes or until bleeding ceases. It should then be sealed up. 

In submucous injections it is best to insert an antiseptic gauze pad for 
a few hours to control the slight oozing and prevent possible infection. 
To prevent the paraffin spreacHng into the neighboring tissues, especially 
when a great deal of loose areolar tissue is present, as in the eyelid, in 
injecting the bridge of the nose, it is good practice to have an assistant 
hold his fingers firmly against the underlying bone on each side of the 
aiva to be injected. 13efore complete hardening of the paraffin takes place 
it should l)e molded to a certain extent. In regard to the operation, it 
may be performed in one or more sittings according to the discretion of 
the surg(<on. It is sal'er to inject at several sittings, because one can 



THE SURGICAL CORRECTION OF NASAL DEFORMITY 



281 



always add to the amount of paraffin, but if too much is injected it is 
very difficult to remove it. 

The complications following injection are: 

1. Infection. 

2. Hematoma. 

3. Embolism. 




Beck's paraffin syringe. 

P^ach is comparatively rare. The first complication sliould be guarded 
against by observing the strictest antiseptic precautions in sterilizing 
the paraffin, the syringe, the field of operation, and the hands of the 
operator and assistants. 

Hematoma is controlled by pressure, and if it is veiy large it may require 
evacuation, followed ])y the aj)])licatioii of ice and afterward warm a])j)lica- 
tions to cause absorption. 



2S2 THE NOSE AXD ACCESSORY SIXUSES 

Eiiibolisin lias boon reported twice in the literature, and in both cases 
ether injected hyj)()dennically in dram doses was successful. 

The change that takes place in the injected mass is at first a reactive 
inflammation forming a fibrous capsule, which soon fills with a new^ trabec- 
u\w, which ramifies the paraffin mass in all directions, until the latter 
is held in a meshwork of fibrous tissue. It has been found that after 
a |)eriod of six months to a year considerable paraffin has been absorbed, 
the connective tissue having taken its place. Cases injected several 
years ago have remained about the same size as when first injected. 
Such a mass after organization is knoAMi as paraffinoma. Exposure to 
excessive heat, as in foundries and following high long-continued fevers, 
as typhoid and pneumonia, has very little effect on the injected mass, 
while traiunatism, as a blow on the nose, has changed the contour of 
an injected nose somewhat. 

Special Technique. — Saddle nose and other malformations of the 
nose. 

1. To fill up a defect: Thoroughly prepare the field of operation and 
place the patient in a recumbent position. Introduce the needle of the 
syringe beneath the skin and fill up the defect either at one or in several 
sittings. Do not dissect the skin loose from the underlying bone, as a 
hematoma will form and become infected. 

Stop oozing by compression and close the puncture with collodion- 
cotton. No after-treatment is required (Fig. 197). 

2. To stiffen collapse of the alse of the nose: The needle point is 
introduced between the cartilage and the skin along the whole alar area; 
inject a very small particle of paraffin to bring about the desired 
effect. 

3. Reconstruction of the inferior turbinated body following atrophic 
rhinitis: Thoroughly cleanse the mucous membrane of pus and crusts. 
Anesthetize that portion of the turbinated body which is to be penetrated 
by the needle with a 5 per cent, solution of cocaine. If a stronger solu- 
tion is used, too much contraction will follow. Use the angular needle 
(Fig. 197) and introduce the same below the mucous membrane close 
to the bone, and pass it back as far as the posterior end, guarding 
against perforating the same. Inject slowly by turning the screw head 
from left to right, and as the needle is withdrawn a track of paraffin is 
left along the course of the needle. Apply an intranasal tampon for a 
few hours. Keep the parts thoroughly clean. It is at times necessary 
to re-inject the different areas. The mucous membrane may be too 
thin to retain the paraffin. (See page KU for a further description.) 

4. Correction of the deformity following the frontal sinus operation : 
Cleanse the skin and introduce the needle point in different directions 
and insert the paraffin, as the scars are usually very firm and do not 
easily elevate. Extreme care must be taken not to pass the needle too 
deep, as the posterior table may be injured. 

.'). Correction of the defects after the mastoid operation requires a 
])reliminary dissection of the skin, which is usually firmly adherent to 
the i)one. This may be done by making a small incision through which 



COLLAPSE OF THE ALM NASI 



283 



a small elevator is introduced. Squeeze out all the blood and fill up with 
the paraffin. Close the opening caused by the elevator by one or two 
horsehair sutures. 




Schema showing the injection of 



n to correct "saddle 



6. Correction of defects caused by excision or disease of the upper 
or lower jaw. 

One must be guided by the disease present and apply the principles 
mentioned above. One of the most common defects is caused by necroses 
following decayed teeth, and secondary periostitis. 



COLLAPSE OF THE AL^ NASI. 



Etiology. — Collapse of the wings of the nose is sometimes associated 
with prolonged nasal obstruction and mouth breathing. Lambert 
Lack suggests that the open mouth, with the resultant drag on the sides 
of the nose, and the atrophy of the dilator muscles of the alee from pro- 
longed disuse are the chief factors in producing the condition. The 
condition may also be due to senile changes. 

Symptoms. — The nasal orifices are greatly narrowed, often mere slits, 
and the ake are flaccid and collapse upon inspiration. Under normal 
conditions the alae dilate and are firm and resilient. 

Treatment. — If the collapse is due to unilateral nasal obstruction the 
cause of the nasal obstruction should be removed. Li some instances 
this is followed by a cessation of the collapse, especially if the condition 
is of comparatively recent occurrence. In older cases the collapse of the 
alse persists. I^ack advises having the patient practise dilating the nostrils 
against resistance. He has them stand before the mirroi- for five to ten 
minutes twice a day and lightly compress the aloe with the thuml) and 



284 



THE XOSE AXD ACCESSORY SIXUSES 



finger, and dilate tlie nostrils to their fullest extent. Tins method gives 
results in recent cases, whereas in old standing cases in which there is 
complete paralysis of the dilator muscles it is ineffective. (See Paraffin 
Injections.) 

Soft- and hard-i-ubber rings (Guye) have been worn to keep the nostrils 
patulous, but the discomfort attending their use is quite objectionable. 
Walsham recommends elevating a narrow strip of mucous membrane 
from the anterior portion of the septum with an attachment above, and 
then rolling it into a mass at the upper angle of the nostril (Fig. 198), 
stitching it in position where it mechanically prevents the collapse of the 
ala. Lambert Lack suggests the most ingenious and apparently the best 
method in obstinate and troublesome cases. "The operation consists 





Fig. 198. — Collapse of the ala nasi connected by a roll of mucous membrane from the septum. 

Fig. 199. — Schema showing Lambert Lack's method of overcoming collapse of the alee nasi. 
The flaps a and b are made from the septum, and are about one-eighth of an inch wide. The 
upper surface of each flap is denuded of mucous membrane, and the nasal walls against which 
they are reflected is curetted to encourage adhesion. The flaps are held in position by a single 
suture in each flap. 



in turning up a piece of cartilage as well as mucous membrane from the 
septum and stitching it across the top of the nostril at right angles to 
the septum, so as to push the ala forcibly outward. An L-shaped in- 
cision is made through the mucous membrane on one side of the nasal 
septum and the mucous membrane detached from the cartilage. A 
small piece of mucous membrane at the top, and extending a little on to 
the outer wall of the nostril, is then cut away so as to leave a bare surface, 
to which the cartilaginous flap becomes adherent. The knife is then 
passed completely through the septum, and a small quadrilateral piece 
of the septum, with the mucous membrane on the opposite side left intact, 
is cut. This flap should be about one-half inch long and one-eighth inch 
broad. It is fixed to the roof and outer wall of the nostril with a single 
stitch. A similar piece is then turned up on the other side (Fig. 199)." 



CHAPTER XVI. 

CHRONIC GRANULOMATA OF THE NOSE, THROAT, AND EAR. 
LUPUS OF THE NOSE. 

Definition. — "Lupus vulgaris; a chronic disease of tlie skin and 
mucous membrane, cliaracterized by tlie formation of nodules of granu- 
lation tissue. It passes through a number of phases, and terminates 
by ulceration or atrophy with scar formation. The cause of the disease 
is the tubercle bacillus." (Gould's Student's Medical Dictionary.) 

Etiology. — Lupus of the nose and upper air passages is practically 
always associated with, or is secondary to, a lupoid condition of the skin 
of the face. Rare instances of primary lupus of the pharynx and larynx 
have been reported by Emil Mayer, Rubenstein, and others. 

Females are more often affected than males, and it is more common 
in the country than in the city. It is more common in middle life, though 
it occurs at all ages. An abraded or diseased mucous membrane predi- 
sposes to its development. While lupus is due to the tubercle bacillus, 
there is a clinical distinction between it and tuberculous ulceration. 
Lupus is slow and insidious in its development, and is not necessarily 
associated with pulmonary tuberculosis. It has a tendency to heal, 
cicatrize, and recur, and does not often result in death from pulmonary 
involvement. 

Symptoms. — Lupus of the nose generally begins on the anterior portion 
of the cartilaginous septum or upon the skin around the nasal orifice. 
It may spread from the septum to the inner wall of the ala. It appears 
as small nodules which coalesce and ulcerate, and it may disappear by 
absorption. The reparative process takes place but feebly at the margins 
of the ulcer, thus forming a pale-bluish, smooth cicatrix. The ulcers 
reappear and then disappear. This process may continue for years 
without spreading to other regions. The nodules are firm and 
well marked. The disease rarely attacks the cartilage and never the 
bones. One or both nostrils may be affected, and there may or may not 
1)6 stenosis. The discharge varies with the stage of ulceration. At the 
onset it is thin and watery, and later becomes thick and even fetid, 
especially after crusts appear. Pain and tenderne s may be present, 
though I have seen cases in which they were absent. Itching is some- 
times complained of. 

Deformity may be present if (he ahe arc involved; when liini((Ml to the 
septtnn it is rarely present. 

Treatment. — Spontaneous rccoNciy in;iy (akc i)l;ic(\ (liougli (liis is 
exceptional. It does not readily yield to treatment. Lcjcal escharotics, 



286 THE NOSE AND ACCESSORY SINUSES 

curettage, the galvanocautery, serumtherapy, surgical removal, and 
radiotherapy have all been tried with more or less success. 

The escharotics used have been lactic acid, carbolic acid, chromic acid, 
the Vienna paste, and other destructive chemical agents. Curettage 
has also been tried, usually with indifferent results. Curettage followed 
by the local application of an escharotic affords somewhat better results, 
though even this is far from satisfactory. The local cauterization with 
the galvanocautery is a procedure often resorted to, though usually with 
negative results. Serumtherapy has been attended by some success, but 
its limited use, thus far, does not afford a sufficient basis for a fair con- 
clusion as to its efficacy. Surgical removal by excision of the diseased 
area is also as ineffectual as the measures just mentioned. It is possible 
that radiotherapy may prove to be of some value in these cases. 

Radiotherapy. — Radiotherapy consists in the local application of 
heat and light rays endowed with a biochemical energy. Generally 
speaking, the blue-violet rays are the most potent, though the ultra-violet 
and .T-rays are also effective. The energy may be applied by the a;-ray 
tube, the Finsen apparatus, the leukodescent lamp, and radium. 

I have only had personal experience with the leukodescent lamp shown 
in Fig. 19. The source of energy is an incandescent lamp of 500 candle- 
power with a specially designed reflector to concentrate the rays upon the 
diseased tissue. A treatment consists in concentrating the rays upon 
the diseased area for a period varying from fifteen to thirty minutes. The 
heat incidental to the applications renders it necessary to interrupt the 
applications every few seconds, during which intervals the skin should 
be gently stroked with the hand to diminish the sensitiveness present. If 
the treatments are to be extended over a period of twenty minutes, the 
lamp should be about eighteen inches distant from the face. If they are 
to be extended only over a period of five minutes, the lamp should be 
passed within three inches of the face for about two seconds at a time; 
that is, two seconds on and two seconds off. The face should be gently 
stroked with the hand during the intervals between the exposures and 
the application repeated. From five to eight such applications, followed 
by fifteen minutes' application at eighteen inches, constitutes a treatment. 

The seances should be repeated daily or every second day until the 
disease disappears. From three to twenty treatments are usually given 
before success or failure is demonstrated. If no impression is made by 
this mnnber of treatments they should be discontinued. 



LUPUS OF THE PHARYNX AND LARYNX. 

Posey and Wright quote H. Myngid's report of 20 patients with 
lupus of the skin in which the larynx was affected in 10 to 20 per cent, 
of the cases. Fifteen of the cases were females and 5 were males. 
Hunt in 411 cases of external lupus found either the pharynx, lar^aix, or 
the nose involved in 20 per cent, of the number. In 173 cases of lupus 
of the mucous membranes in Doutrelj)ont's clinic, only 6 cases were free 



TUBERCULOSIS OF THE NOSE 287 

from cutaneous lesion. The nose was affected in 75 cases, the palate in 
31 cases, and the larynx in 13 cases. The lesion often appears before 
puberty. (See Lupus of the Nose for a more general discussion of 
lupus.) 

LUPUS OF THE AURICLE. 

Lupus of the auricle manifests itself in all the forms found on other 
parts of the body, namely, hypertrophic, macular, papillary, and ulcer- 
ous, and is usually an extension from the face. 

It begins with tubercles the size of a pinhead or larger, which are 
brownish in color, and slightly scaly on their surface. They are ar- 
ranged in groups, and are surrounded by a slight efflorescence. The 
skin is contracted around the diseased areas. The scarred appearance 
is due to the deep penetration of the tubercles. Keloid formations are 
quite common. 

The ulcerous type is rare and is characterized by ulcerations covered 
with thick crusts beneath which there is a spongy base. The edges of 
the ulcers are undermined and pale, with an occasional typical lupus 
nodule. 

Treatment. — The treatment of lupus has been so uniformly suc- 
cessful under the Finsen phototherapy, the Rontgen-ray, and the 
leukodescent light that the older methods of treatment have become 
almost obsolete. 

Hollander reports excellent results following the application of hot 
air to the diseased surfaces. The method is worthy of trial, espe- 
cially if the Finsen, Rontgen-ray, and leukodescent light treatments 
are not available. The hot air may be applied with Beck's hot-air 
apparatus, hoping thereby to stimulate regeneration of the tissues and 
to relieve the subcutaneous edema which accompanies lupus. 

If simpler methods of treatment fail the lupus areas may be excised 
and a subsequent plastic operation performed to overcome the defor- 
mity resulting from the primary operation. Another form of treat- 
ment, much in vogue in Europe, is to first curette the granulating areas 
and then apply a paste, the base of which is arsenic. This same mode 
of treatment has been much vaunted in this country by charlatans as a 
means of curing cancer. Most of the cancerous cases being, however, 
one or the other of the types of lupus heretofore mentioned. The 
actual cautery may be used instead of the curette and arsenic paste. 



TUBERCULOSIS OF THE NOSE. 

Tul)(Mvul(Mis infection of the nose is characterized by either a low-grade, 
slightly depressed ulcer on the anterior portion of the septum or floor 
of the nose, or a sessile, wart-like tumor in which the tubercle bacillus 
is present. 

Tuberculous lesions of the nose may be primary, or secondary to a 



28S 



THE \OSI-: AM) ACCESSORY SI.XUSES 




similar process in the lungs. It is generally secondary, though cases are 
not rare in which the process is limited to the nose. I reported a case 
which was under the care of the late Dr. ]\lax Thorner, of Cincinnati, 
for about foiu' vears. It was subsequently under my care for about the 
same time, and is now under the care of a confrere, who informs me that 
the ulcerous condition has yielded to applications of the high-frequency 
currents of electricity. It should be noted, 
however, that the patient spent the winter 
in the South, and that while under my care 
the ulcer disappeared spontaneously each 
summer. 

The case has thus been under nearly 
constant observation for about eighteen 
years. The patient is about forty-five 
years of age, and is in robust health, never 
having had any pulmonary symptoms. She 
says her brother has a similar condition in 
his nose. I inoculated a guinea pig with 
he tissue removed by curettage, and in six 
weeks the postmortem showed extensive 
tuberculous lesions in the neighboring 
glands and in the mesentry. The tuber- 
cular ulcer (Fig. 200) w^as superficial, irreg- 
ular in outline, and had a somewhat nodular 
surface covered with crusts. It bled easily 

vation five years, and under Dr. Max upOU probiug, WaS painlcSS, and disappeared 
Thomer's observation four years pre- ^^^^^.j^ ^j^^ sumuicr UlOUths, Icaviug a 

viously. It IS now under the obser- i • i i • • • i p 

whitened, rather smooth cicatricial surface. 
It reappeared in the autumn of each year, 
only to disappear the following summer. 
This case seems to be primary in the nose, 
and shows little or no tendency to spread. 

author's care, and recurred r'^gularl'y There is nO lupUS Icsion of the skiu. 

each November. Varieties: (a) Superficial ulceration, (h) 

Wart-like or sessile tumors. 

The superficial ulcers are the most common. 

The wart-like growths are hyperplastic, and, like the ulcerous variety, 
bleed easily. The removal of either variety is followed by rather slow 
healing and l)y subsequent recurrence. 

The complications are perforation of the septum and extension to the 
skin of the u j)per li[), and in extremely rare instances to the nasal accessory 
sinuses. Kyle suggests that the low resistance of the tissues affords a 
suitable soil for all forms of chronic granuloma microorganisms. The 
treatment consists in curettage and the application of Vienna paste. The 
ulcer or tumor should be anesthetized with a 5 to 10 per cent, solution 
of cocaine, after which the diseased area should be thoroughly curetted. 
A light ap])lication of Vienna paste may then be made to ensure the 
destruction of remainino- frao-ments of tuberculous tissue. The radiant 



Tuberculous ulcer of the cartila- 
ginous portion of the septum. The 
case was under the author's obser- 



vation of Dr. J. C. Beck. The author 
injected a guinea-pig witli tissue re- 
moved from the ulcer, under strict 
aseptic precautions, and found tuber- 
culosis upon postmortem examina- 
tion. The ulcer healed regularly 
every summer while under the 



TUBERCULOSIS OF THE PHARYNX AND THE FAUCES 289 

energy of the leukodescent lamp, Finsen light, or some other source of 
radiant energy may be tried, although I am not informed as to their 
beneficial effects in this condition. 

In spite of all forms of treatment there is a strong tendency for the 
tuberculous lesion to persist, and if it disappears, to return. 



TUBERCULOSIS OF THE PHARYNX AND THE FAUCES. 

Tuberculosis of the pharynx and fauces is rare and is probably always 
secondary to pulmonary or laryngeal tuberculosis. It is usually asso- 
ciated with, and is probably an extension from, tuberculous laryngitis. 
It has no point of attack, but may begin in the soft palate, uvula, tonsils, 
lingual tonsils, or the pharyngeal mucosa. Unlike nasal tuberculosis, 
it tends to spread rapidly to adjacent parts. 

The part affected presents a wormeaten appearance, the ulcers being 
surrounded by an area of congestion. The ulcers are superficial and 
covered with a dirty grayish secretion. They bleed easily upon probe 
pressure. There is httle or no induration except at the borders of old 
chronic ulcers. When the lingual or faucial tonsils are the seat of 
ulceration the depth of the ulcer is greater; even the whole tonsil may be 
destroyed. Cases are reported in which the faucial tonsils were the 
seat of primary infection and infiltration. It is, perhaps, impossible to 
estimate the proportion of cases that are primary in the tonsils, though 
it is perhaps larger than is generally supposed. In other portions of 
the pharynx and fauces it is rarely primary. The infection occurs either 
through the lymph channels or by the contact of the infected sputum 
with the mucous membrane. 

Symptoms. — The symptoms vary with the anatomical location and 
extent of the lesion. If the soft palate is involved the proper approxi- 
mation of the palatal muscles to the posterior wall of the pharjaix is 
interfered with, and fluids and solid food may enter the nose upon 
deglutition. The same condition allows the secretions to accumulate and 
dry in this portion of the pharynx. This leads to hawking the nausea 
in the effort to dislodge it. An infiltration of the uvula may cause pain 
and a tickling cough. As the secretions are thick and the parts often 
exceedingly painful the secretions are often allowed to accumulate. 
The voice is muffled and hoarse, or aphonic. 

Diagnosis. — Syphilis is about the only disease with which tuberculosis 
of the pharynx may })e confounded. The following tables adapted 
from Lennox Browne will aid in the diagnosis. 

Tuberculous Ulcers. Syphililic Ulcers. 

1. Superficial motheateri surface. 1. Deep red and angry surface. 

2. Mildly red areola. 2. Angry red areola. 

3. Ragged, ill-defined edges. 3. Sharply cut edges. 

4. Indistinct demarcations. 4. Distinct demarcations. 

5. Grayish ropy secretion. .5. Purulent yellow secretion. 

6. Scantj^ secretion. 6. Profuse secretion. 
19 



290 THE NOSE AXD ACCESSORY SINUSES 

Prognosis. — The j)rogiiosis is grave. In those cases in which it is 
primary in the tonsils it is not so serious. When we remember that 
tul)crcuk)sis of the pharynx is nearly always secondary to pulmonary 
involvement the gravity of the disease is apparent. Kanasugi regards 
])haryngeal tuberculosis as being more grave than any other localized 
type, an(J the primary more than the secondary. 

Treatment. — Curettage followed by the application of piu-e lactic acid 
is a common form of treatment. It is doubtful if climatic or outdoor 
treatment is as effective, as the pulmonary involvement is usually well 
advanced. Forced feeding on raw eggs and milk should be a part of 
the treatment of all tuberculous diseases when there is loss of weight and 
strength. The local application of a 2 to 10 per cent, solution of formal- 
dehyde should be tried as in lar}Tigeal tuberculosis. The pain should 
be controlled by the local application of cocaine, the administration of 
opiates, or the leukodescent light or other radiant energy. Painful 
deglutition is relieved by the application of cocaine immediately before 
meals. 

TUBERCULOSIS OF THE LARYNX. 

Synonyms. — Consumption of the lar}Tix; consumption of the throat; 
laryngeal phthisis; tuberculous laryngitis. 

Definition. — Tuberculosis of the lar\aix maybe primary or secondary, 
and is characterized by an infiltration of the glands and connective tissue 
of the larynx. It gives rise to dysphagia, aphonia, and dyspnea. 

Etiology. — The view that laryngeal tuberculosis is always secondary 
is held l)y almost all observers, and is proved by the findings of autopsies, 
there being very few recorded cases of death by laryngeal tubercidosis 
in which either a healed or active pulmonary involvement has not been 
found. The opponents of this view are very few in number, the most 
prominent of them being Dr. Gleitsmann, whose researches have been 
extensive, and who reports two cases of primary laryngeal and pharyngeal 
tuberculosis in his own practice wdiich were cured. In the report of his 
cases he quotes Demme, E. Fraenkel, Prof. Rebinski, Orth, Coghill, 
J. S. Cohen, Dehio, and Lance reaux in support of his view. 

Goodale has seen many cases of tuberculous laryngitis which he thought 
were primary, and which for a time seemed to yield to treatment; but the 
subsequent progress of the disease always proved fatal through the 
associated pulmonary tuberculosis. It is possible in a suspected in- 
stance of tiibei-culous laryngitis, where the pulmonary signs are negative, 
that a radiograph may disprove or substantiate the presence of 
pulmonary tuberculosis. Demme, in 1883, reported the case of a boy, 
aged four and one-half years, who died of tuberculous meningitis; the 
necropsy showed the presence of laryngeal ulceration with tubercle 
l)acilli, the thorax and abdominal organs being at the same time free of 
tuberculous disease. He says many other cases in which such a condi- 
tion was suspected have also been recorded; and it may now be considered 
as an accepted fact that tuberculous disease may not only attack the 
larynx primarily, but even cause death without the lungs being affected. 



TUBERCULOSIS OF THE LARYNX 291 

The disease is more common in men than in women, and occurs 
especially between the ages of twenty and forty years. 

Knight also quotes Heinze's statistics, and adds that of the laryngeal 
lesions more than one-half were ulcerative, a proportion confirmed by the 
Brompton Consumption Hospital, nearly twice as large a percentage as 
that given by many other investigators. The mode of invasion of the 
larynx is either by direct infection through the inspired air or by the 
expectorated sputum, or indirectly by conveyance of bacilli from the 
tuberculous foci in the lungs through the blood current or lymph channels. 
The latter route is doubtless more frequent. If the contrary were true, 
tuberculous laryngitis would be much less rare than it is. The apparent 
immunity of the larynx against primary infection is difficult to explain. 
There is no essential difference between the mucous membrane of the 
larynx and the nose and other portions of the upper respiratory tract, 
excepting the pharynx. The mucosa of the nose is more exposed to the 
irritating influence of the atmosphere, and to trauma from picking crusts 
from the vestibule, and in this respect the abrasions offer a favorable site 
for the infection; the larynx is also subject to abrasions in the course of 
chronic laryngitis and in excessive use of the voice, and it yet remains 
to be proved that under these conditions it becomes the seat of primary 
tuberculosis. Shurley contends that the ventricles of the larynx afford 
a sheltered, quiet place for the development of the tubercle bacilli, and 
that in spite of this fact they do not readily develop here. The hidden 
recesses of the crypts of the tonsils aho afford an ideal place for the 
growth of the bacilli, and, according to Mayo, 8 per cent, of all tonsils 
removed by him are tuberculous. Robertson's statistics support Mayo's. 
There is the necessary temperature, quiet, and protection from the 
currents of air to favor such a process. The tonsils are undoubtedly a 
common source of infection. Having gained entrance to the lymphatic 
circulation by this route, they travel downward to the lymphatic glands 
of the anterior triangle of the neck, thence to the lymphatic glands of 
bronchial tubes, and from there to the substance of the lung. I believe 
that the explanation of the apparent infrequent primary involvement 
of the larynx is to be found in inherent resistance of all mucous mem- 
branes to the invasion of the tuberculous germs, and that the exceptions 
to the rule are in the nasal mucous membrane of the anterior portion of 
the cartilaginous septum and the mucosa of the tonsil crypts, where 
the abrasions are so often present, and where the conditions are 
exceptionally favorable for the growth of the bacilli. The site for the 
tuberculous infection of the nose is at the point where it is or may be daily 
denuded of its epithelial covering, and where the deposit of tubercle 
bacilli is abundant. It would be strange, indeed, if tuberculous infection 
did not occur under these circumstances. The tonsillar crypts form 
ideal sites for the growth of the bacilli, being warm, practically without 
motion, iind plugged with secretion, food, and desquamated epithelium. 
In these hidden recesses the bacilli flourish and remain constantly in 
contact with the mucous membrane. The crypts are also the site of 
frequent infianunations, during which the epithelium may be impaired. 



292 THE XOSE AND ACCESSORY SIXUSES 

thus affording a favorable condition for the invasion of the tubercle bacilli 
into deeper lymphatic tissue. Indeed, during inflammations the inter- 
cellular spaces become larger and permit the bacilli to pass through. 
It is more than probable that when the bacilli are indefinitely lodged on 
a mucous membrane they may penetrate through these spaces without 
an abrasion being present. The favorable conditions existing in the 
nose and tonsils are not present in the larpix, hence the tubercle bacilli 
rarely primarily infect the lar^aix. When, however, pulmonary tuber- 
culosis is established, and the expectorated sputum constantly bathes 
the laryngeal mucous membrane, the conditions for infection are much 
more favorable. The constant presence of the bacilli, the mechanical 
irritation, the abrasions produced by coughing, and the lowered resistance 
of the celhdar structures in general combine to favor such an infection. 
It is probable, therefore, that infection is usually secondary to the pul- 
monary involvement, and not primary. 

Pathology. — The first apparent change in the larynx may be an 
ischemia of the mucous membrane. This is usually referred to as an 
"ashen-gray" color, which is said to be pathognomonic of tuberculosis. 
It is not always so, however, as it may occur in any general anemia. 
I have in several instances been enabled to make a diagnosis of tuber- 
culosis by the "ashen-gray" color before the stethoscope showed positive 
evidences of the disease in the lungs. I referred these cases back to 
their physician with the suggestion that he apply the tuberculin test, 
and in each instance a typical reaction occurred. I contend, therefore, 
that while the "ashen-gray" color is not pathognomonic of tuberculosis, 
it is, nevertheless, a valuable early sign in many cases, especially when 
there is a pulse of 100 or more and a daily rise of temperature. It 
should be stated that the mucous membrane of the lar^^lx is not always 
of an "ashen-gray" color in tuberculosis, but, on the contrary, it may be 
quite red, inflamed, and indurated. The vocal cords may be hyperemic 
and swollen until their indentity is lost in the reddened mucous mem- 
brane, or they may be lax, flabby, and nodular. 

The histological changes occur chiefly in the aryteno-epiglottidean folds, 
the interarytenoid space, and the epiglottis. The cartilages may become 
involved, thus giving rise to perichondritis and chondritis. Cicatricial 
contraction takes place as the healing process progresses. This may give 
rise to more or less dyspnea. 

When the arytenoid cartilage is affected the clubbed-shaped infiltration 
tumor is present (Fig. 201). When the infiltration extends to the aryteno- 
epiglottic ligament the picture is quite characteristic of tuberculosis of 
the larynx. 

The epiglottis is often involved in the process, and when infiltrated 
presents the turban shape so often referred to. The infiltration may 
extend to both sides of the larjTix or l)e limited to one. When both are 
affected the view of the deeper portions of the larynx is hidden. The 
tendency to ulceration is quite constant. It is rare for a well-advanced 
case of laryngeal tuberculosis to be free from it. The ulcers may be of 
any size within the limits of the area involved, and may be superficial 



TUBERCULOSIS OF THE LARYNX 



293 



or extend to the cartilages. They may be discrete or confluent, single 
or multiple, and on one or both sides. When the cartilage is involved 
by ulceration there is a purulent discharge from the mixed infection 
present. Tuberculous ulcers develop more slowly than syphilitic ulcers 
and are less destructive, and are followed by less cicatricial contraction. 

Symptoms. — The symptoms of an ordinary case of laryngeal tuber- 
culosis are so characteristic there is little difficulty in making a correct 
diagnosis. As the laryngeal involvemen is usually secondary to a 
pulmonary involvement the preced ng history may afford an excellent 
index. There is more or less cough, 
often without expectoration, and there fig. 201 

may be a sense of prickling or dryness 
in the throat. The voice may be hoarse 
or aphonic. When the infiltration is 
extensive the voice is often aphonic. 
The dyspnea is in proportion to the 
degree of infiltration and the cicatricial 
contraction present. Pain may or may 
not be present. In some cases it is 
quite severe, requiring the local appli- 
cations of cocaine and orthoform, or 
injections of morphine to control it. 
In one of the author's cases, illustrated 
in Fig. 201, though the patient is 
aphonic, and has been for several 
years, there is no pain. Dyspnea is a 
constant factor though not alarming in 
severity. During the past six years 
the patient has gained twenty-six 
pounds in weight. Difficult or painful 
deglutition has been a more or less 
prominent symptom. The laryngo- 
scopic examination shows the lesions 
described under pathology. 

Diagnosis. — Laryngeal tuberculosis must be differentiated from 
syphilis, carcinoma, and lupus. 

Syphilis of the larynx presents a " punched-out" ulcer with a yellowish 
exudate. It spreads rapidly. The voice is low pitched and hoarse, 
or raucous, rarely aphonic. Pain is present upon phonation. The 
tuberculous ulcer is superficial and its base covered with a grayish exudate. 
It spreads rather slowly, is painful upon deglutition, and the voice is 
weak and softly hoarse or aphonic. 

In carcinoma the base of the ulcer is raised by the crowding of the 
deeper infiltration; it is red and constantly painful, and the voice is 
continuously loose. 

In lupus there is usually no pain, ulceration, edema, or discharge; 
dysj)nea is slight or absent, the general health good, and a lupoid lesion 
is usually present upon the skin. 




Tuberculosis of the larynx. There is a 
bilateral pyriform infiltration of the ary- 
tenoids and of the right half of the epi- 
glottis. The surface of both arytenoids is 
ulcerated, and the vocal cords are ragged. 
The patient is aphonic, is still living, and 
has increased several pounds in weight. 
(Author's ease.) 



294 THE NOSE AND ACCESSORY SINUSES 

Prognosis. — The prognosis in laryngeal tnberculosis is grave, though 
not necessarily fatal. According to Ilarpy there were 14 spontaneous 
recoveries in 3000 cases. Under apj^ropriate treatment the percentage of 
recoveries is increased. As a rule, however, the patient or his friends 
should only be encouraged to expect the patient to live for a comparatively 
short time — a few montlis or years. Death may occur from inanition, 
suffocation, or hemorrhage. 

Treatment. — The treatment of laryngeal tuberculosis, excepting the 
local symptoms, is the same as in pulmonary tuberculosis. At present 
the "outdoor" treatment, especially in the earlier stages, is enthusias- 
tically recommended. The tent colony at Ottawa, Illinois, under 
the super^^sion of Dr. J. W. Pettit, is doing good work. The buildings 
are so arranged that the patients practically live outdoors the year 
round. While this at first thought seems impossiWe during the winter 
montlis, it is, nevertheless, being done with comparative comfort. The 
house or tent protects from the severe cold and from the winds, while 
fires make life not only tolerable, but cheerful and comfortable. The ob- 
ject is to keep the patients in a pure circulating atmosphere, and sunshine 
as nearly all the t"me as possible. The whole system is thus invigorated 
and the lungs supplied with fresh oxygen. The vital forces are aug- 
mented and the reparative processes are often quickly and permanently 
restored. In mild cases, and in the incipient stage, little or no medicinal 
treatment is required, the "outdoor" treatment being quite sufficient. 
In well advanced cases where there is great infiltration and ulceration of 
the laryngeal tissues the "outdoor" treatment is as ineffectual as any 
other form of treatment. Innumerable remedies are recommended for 
the cure and relief of larpigeal tuberculosis, among them being the 
following : 

For the relief of cough: codeine, s to ^ grain every three hours. Mor- 
phine sulphate, -o^ to ^rr grain every three hours. 

For the relief of pain: Spraying the larynx with a 0.5 per cent, 
solution of cocaine. If there is painful deglutition, cocaine may be applied 
locally, just before eating, in a strength of 2 to 8 per cent. Insufilations of 
orthoform powder may be made to relieve the pain. It is non-poisonous, 
and its effects last longer than those of cocaine. 

For curative effects, Gallagher, Levy, Lockard, and Jolmson make 
local applications of formaldehyde to the lar}Tix, with beneficial results. 
Gallagher was the first to prove its beneficial action in tuberculosis of 
the larynx. It should be used in increasing strength, beginning with a 
0.5 per cent, solution and gradually increasing it to 10 per cent. The 
patient may be entrusted with a 1 to 500 solution for home treatment, 
greater strengths being applied by the attending physician. 

Gallagher has had excellent results with the following method of 
treatment: 



TUBERCULOSIS OF THE LARYNX 295 

1. Anesthesia slight. 

2. Cleanse, spray with 1 to 3 % formaldehyde solution. 

3. Local application, 5 to 10 % formaldehyde. 

4. R. — Orthoform 7 parts 1 . ^ ^. 

, . , , 1 i r insufflation. 

Aristol 1 part I 

5. Deep intratracheal injection of 

I^. — Menthol gr. x— gr. 1 

01. eucalyptus oJ-5iJ 

01. cinnamon gtt. j-gtt. x 

Glycerol q. s. ad §j 

The above daily. Curettage is used when deemed necessary. 

Menthol is another remedy of positive vahie. It may be used in 
combination with camphor and orthoform. Freudenthal uses it in 
emulsion in the following proportions: 

3^. — Menthol 1 to 15 parts. 

01. amyg. dulu 30 parts. 

Vitelli ovarum 25 parts. 

Orthoform 123^ parts, 

AquEB des q. s. ad 100 parts. 

Ft. emulsio. 

The above is injected intratracheally and often yields excellent results. 

Lactic acid has had and still has its advocates. Begin with a 10 per 
cent, solution and increase to 75 per cent., or even full strength. It 
should only be used when there are ulcerations or after curettement. 
It should he rubbed into the ulcerated or raw surface with a cotton- 
wound applicator at intervals of five to ten days. The pain is severe and 
continuous for four or five hours. 

Radiotherapy. — According to Gleitsmann the Finsen light and the 
ultraviolet rays are less penetrating than the Rontgen rays, and yet the 
great expectations from the latter in laryngeal diseases have not been ful- 
filled. The bacilli are at first increased, and only after a prolonged use 
of a low vacuum tube is improvement noticeable. The Cooper Hewitt 
light, or mercurial waves, the search light, the actinolight, and the leuko- 
descent lamp may be used to relieve the pain, and in some instances actual 
improvement follows. It is too early to predict marked curative power 
from these sources. I have used the leukodescent lamp, but my 
experience in laryngeal tuberculosis is too limited to state that it does 
more than relieve the pain. The chief value of the leukodescent lamp is 
in the blue-violet rays and the radiant heat. These in combination 
exert a favorable influence in acute catarrhal and suppurative inflam- 
mations, hence are of service in combating the mixed infection usually 
present in tuberculosis. The use of radium as reported by J. C. Beck 
relieves the pain just as other forms of radiant rays do. The direct rays 
of the sun act in much the same way. 

(Airettage should be limited to the ulcerated areas, carefully avoiding 
the parts which are simply infiltrated and have an imbroken surface. 
It has been conclusively shown that the infiltrated areas may remain 
quiescent indefinitely. Having curetted the tuberculous ulcer, stimulating 
the sluggish process, and removing the overlying necrotic tissue, the local 
treatment given in the preceding paragraphs should be continued. 



29B THE XOSE AXD ACCESSORY SIXUSES 



TUBERCULOUS LARYNGITIS IN PREGNANT WOMEN. 

Lohnberg observed 5 cases in two years. In 2 there was no evidence 
of tuberculosis elsewhere, and in the others the laryngitis overshadowed 
the other lesions. The latter was true in the cases reported by Tiirck. 
Lohnljerg has collected 21 similar cases from the literature. The 
evidence is in favor of the assumption that pregnancy affords a predis- 
j)()sition to this affection and whips the latent process to a gallop. Further- 
more, he says that every pregnant woman with diffused larpigeal tul)er- 
culosis is immediately doomed, and possibly also those with only a 
single tubercle. The only treatment is the palliative use of menthol- 
orthoform emulsion, formaldehyde, etc., but these lose their eflBcacy 
after a time, and relief is only obtained from morphine and tablets of 
cocaine. 

Pregnant women should be carefully examined at the slightest sus- 
picion of trouble in the throat, and should be placed upon the treatment 
outlined above, and especially the outdoor treatment. Every woman 
should be warned that the tuberculous process may be aggravated by 
pregnancy. It therefore follows that an unmarried woman suffering 
from tuberculosis should not marry until a cure has been effected. 



TUBERCULOSIS OF THE MIDDLE EAR AND MASTOID PROCESS. 

Tul)erculosis of the middle ear may be primary or secondary. A. W. 
Milligan believes the primary form, especially in young children, is 
more common than is generally supposed. Secondary tuberculosis of 
the middle ear is usually a complication of a tuberculous process in some 
other part of the upper respiratory tract, rather than a complication of 
a similar disease of the bones, glands, or abdominal viscera. In a series 
of cases reported some years ago Milligan found 16 per cent, of all 
adenoid cases to be tuberculous. This is a possible explanation of the 
fi-('(|U('nt involvement of the middle ear. 

Symptoms. — The symptoms of tuberculosis of the middle ear vary 
with the acuity, intensity, or the chronicity of the process; also with a 
simple or a mixed infection. 

The acute variety is characterized by some redness of the drum mem- 
brane, slight pain, and multiple perforations. The hearing is consider- 
ably impaired. The facial nerve may be paralyzed. If the infection 
becomes mixed, the nature of the disease is obscured by the greater 
intensity and destructive character of the inflammatory process. 

Diagnosis. — The chronic variety and more usual form is readily 
diagnosticated, as it runs a slower course and is characterized by less 
impairment of hearing (though this is variable), tinnitus, a sense of 
fulness in the affected ear or ears, and an almost or quite complete 
absence of pain. In the early stage there are multiple perforations, 
each ])erf()rati()n being the site of n tu])ercle which has l)roken down. 



I 



TUBERCULOSIS OF MIDDLE EAR AND MASTOID PROCESS 997 

Later these coalesce and form larger perforations, often resulting in 
a most complete destruction of the membrana tympani. 

To confirm the diagnosis, the secretions and the granulation tissue 
should be examined for the tubercle bacilli and giant cells. Should they 
not be found, a guinea-pig should be inoculated with some of the tissue 
and at the end of five to eight weeks examined for the results of the test 
In one of my cases the microscopic findings were negative, but the 
inoculation experiment was decidedly positive. Climatic treatment in 
Colorado and permanent residence there resulted in an apparent 
cure. 

Milligan draws the following conclusions ; 

(a) A final and exact diagnosis is imperative both from the point of 
view of prognosis and of treatment. 

(b) The disease is most frequently found as secondary to a tuberculous 
process in other regions of the body. 

(c) Primary tuberculous disease of the middle ear is probably of more 
frequent occurrence than is usually supposed. 

{d) The prognosis is always grave, but in a certain proportion of cases 
suitably planned surgical intervention will eradicate the disease. 

(e) In many cases it is advisable to conduct the treatment in stages. 

(/) When less than 10 per cent, of the hearing power remains no 
attempt should be made to preserve the ear as an organ of sense. 

(g) When more than 10 per cent, of the hearing power remains in a 
patient otherwise in apparent health a definite attempt should be made 
to preserve the remaining hearing power. 

(h) When the tuberculous origin of the ear disease has been scientifi- 
cally demonstrated the case should be regarded as infectious and precau- 
tions taken accordingly. 

Robert Levy has had exceptional opportunities to study middle-ear 
diseases in tuberculous patients as seen in Colorado. He summarizes 
as follows: 

Any of the usual afi^ections may affect the tuberculous as well as the 
non-tuberculous. 

The usual modifications of an acute otitis in a tuberculous subject 
is manifested in the course the disease pursues. 

It is doubtful whether the Bacillus tuberculosis is present as a dis- 
tinctly etiological factor or as an accident. 

Clinical tuberculous otitis occurs with moderate frequency in Colorado, 
being secondary to lesions of the respiratory organs. 

Tuberculous otitis may develop when the general symptoms of tuber- 
culosis have been arrested and the patient's condition is unusually good. 

Tubercle bacilli may find their way into the middle ear through the 
Eustachian tube, through the lymph channels, or the blood cin-rents. 

Unusual care must be exercised in the application of the nasal douche 
in tuberculous patients. 

The discharge may be arrested, but not permanently, as a rule. 

It must be exceedingly rare for miliary tuberculosis to develop from an 
otitis as the focus of infection. 



298 TH?: NOSE AXD ACCESSORY SIXUSES 

Treatment. — General and climatic treatment must be conscientiously 
carried out. 

(ioldstein reports four cases which he considers were primary tuber- 
culous infections. All of these cases, he says, were seen more than three 
years previous to his report; three are still living, and careful physical 
examination fails to show any tuberculous infection. There were no 
evidences in the histories of these cases or in their clinical development 
either of an acquired or hereditary tuberculosis. Of the 4 cases, 3 
involved the mastoid cells extensively and showed an unusually active 
and rapid invasion. All of the cases developed from a preexisting otitis 
media suppurativa chronica, and appeared to him as direct infection 
by the Bacillus tuberculosis. In the 3 cases where the mastoid operation 
was performed the wounds healed by firm granulations, and all evidence 
of tuberculous trouble ceased with the removal of the local process. 
This is in direct contrast to the healing of wounds in patients in whom 
the systemic tuberculous invasion is present. The data which has 
been furnished in the cases herein reported point to a definitely local- 
ized specific infection of the cavum tympani and mastoid cells, with the 
characteristic development of a tuberculous process as it occurs in bone 
tissue, and with the definite demonstration of the Bacillus tuberculosis 
in one case. 

Prognosis. — Generally speaking the prognosis is unfavorable. There 
are, however, numerous exceptions to the rule. 

Unfavorable. — (a) It is especially unfavorable in those cases running 
an acute course. 

(6) Rapid destruction of bony tissue of the labyrinth and mastoid 
process is another unfavorable sign. 

(c) ]Mixed infection adds to the destructive nature of the process. 

(cl) Well-advanced pulmonary tuberculosis renders the prognosis 
unfavorable. 

(e) ^Marked general debility from any cause is an unfavorable 
sign. 

More Favorable. — (a) In children the disease is often local or secondary 
to diseased cervical glands. The removal of the cervical glands and of 
the diseased centre in the mastoid process is usually followed by complete 
recovery. 

(6) In adults otherwise healthy the prognosis under simple treatment 
is good. 

Treatment. — The treatment should be selected with reference to the 
type of manifestation the age and general health of the patient. 

(a) Primary tuberculosis of the mastoid process yields good results 
under the mastoid operation, especially in children. It children it may 
be necessary to remove the cervical glands, as a failure to do so subjects 
the patient to the liability of a return of the process. 

(h) When the pulmonary fiihcrculosis is not advanced the mastoid 
operation is indicated, and may be followed by very satisfactory results. 
These cases also do well in a suitably selected climate or in tent colonies, 
with ade(juate notu-ishment and local treatment. The tuberculin 



SYPHILIS OF THE NOSE, PHARYNX, FAUCES AND TONSILS 299 

treatment is of value if Koch's new tuberculin is given under opsonic 
control. 

(c) When the pulmonary tuberculosis is well advanced, operative 
treatment is useless. Even in more favorable cases the operation may be 
only followed by a temporary improvement. If the patient is greatly 
debilitated from any cause, operative treatment is contra-indicated. 
In such cases the necrotic process usually continues, the bony walls 
remaining denuded and covered with pus. 

(d) When there is mastoid swelling or redness an early operation for 
the relief of the abscess is indicated, regardless of the general character 
of the disease. 

(e) Climatic or open-air treatment and reconstructive remedies should 
be used in those cases in which there is httle or no lung involvement, 
outdoor air and sunshine being especially recommended. 

O. J. Stein recommends the use of formaldehyde, a few minims of 
which are dropped on a gauze dressing placed in the meatus and auricle. 
This should be covered with a thin layer of cotton and sealed with collo- 
dion to prevent external evaporation. The fumes of the formalde- 
hyde penetrate to the diseased area and exert a favorable influence 
upon it. (See Treatment of Laryngeal Tuberculosis). 



SYPHILIS OF THE NOSE, PHARYNX, FAUCES AND TONSILS. 

The fauces and pharynx are second only to the skin as sites for the 
manifestation of constitutional syphilis, particularly in the secondary 
stage. This may be accounted for in part by the presence of a large 
number of lymphoid glands, the excessive friction, and the complex 
embryological union of tissues in this region. 

Congenital syphilis is more common in the pharynx than it is in the nose. 
The cases shown in Figs. 202 and 203 involved the pharynx and nose. 
John Mackenzie says 50 per cent, of the congenital cases occur in the 
first year of life, while 33 j per cent, were within the first six months. 

Primary lesion of the pharynx and tonsils is second in frequency to 
the genitalia, owing to the numerous syphilitic nurses, sexual perverts, and 
the use of unsterilized surgical instruments in office practice. In one of 
my cases the primary lesion occurred on the left tonsil, which was incised 
for quinsy by a practitioner who was affected by syphilis. 

When 1 first saw him there was an ugly superficial ulcer with indurated 
edges on the upper portion of the tonsil. Within a few days the typical 
secondary rash appeared, thus confirming the diagnosis. 

Females are more often affected than males, and one or both tonsils 
may be the seat of the primary lesion. 

The primary lesion is usually of short duration, though when on the 
tonsils the inflammation may be so great as to extend the period of 
ulceration to the second stage. Tliis has been true in some of my cases. 

The secondary lesion consists of the usual erythema of the face and 
body and mucous membranes. They may appear from six to eight 



300 



THE NOSE AXD ACCESSORY SIXUSES 



weeks after the initial lesion or even as late as several months. The 
ervthematous patches in the throat have been described as ulcerations, 
though Lennox Browne claims they are not true ulcers, but simple 
abrasions of the surface epithelium. 

The tertiary lesions appear from three to twenty-five years after the 
primary manifestation, and may be ulcerative, gangrenous, and gumma- 
tous and very destructive to both soft and bony tissues. 

Symptoms. — The symptoms of the primaiy stage are ulceration with 
indurated etlges, attended by pain in the ear if the arch of the fauces is 
affected. If the inflammation extends to the phar^Tlgeal orifice of the 
Eustachian tube there is some deafness and tinnitus. The lymphatic 
glands of the neck are usually enlarged. 





Fig. 202. — Syphilitic stenosis of the fauces and pharynx. (Author's case.) 
Fig. 203. — Author's case of .syphihtic ozena and ulceration of the margins of the right wing of 
the nose and of the u|)per lip in a cliild four years of age. Inherited syphilis. 



In the secondary stage there may be cough or a tickling sensation in 
the throat. In some cases pain or a dull aching is complained of. 
Dysphagia and a pseudomembranous angina, accompanied by a slight 
elevation of temperature, may be present. Erythematous patches on 
the skin and in the throat may be present, those in the throat often being 
mistaken for superficial ulcerations. Upon close examination they are 
found to be mere abrasions or elevations of the superficial epithelium. 

In the tertiary stage the odor is characteristic, and is kno\Mi as syphilitic 
ozena. There is some pain, but it is not as severe as the lesion seems 
to warrant. The pain is increased uj)on deglutition. 



SYPHILIS OF THE LARYNX 301 



SYPHILIS OF THE LARYNX. 



The primary, secondary, and tertiary manifestations of syphilis may 
appear in the larynx, though the primary lesion is extremely rare. 
Syphilis of the larynx is estimated as comprising all the way from 1 
to 1.5 per cent, of all cases of syphilis. Its occurrence in the pharynx 
is given as about 10 per cent., and in the nose as nearly 3 per cent, of all 
cases. About one-fifth of all the cases of syphilis appear, therefore, to 
affect some portion of the upper respiratory tract. 

It occurs most freciuently between the twentieth and fiftieth years of 
life. In the congenital form it appears either in the first few months of 
life or at about the age of puberty. When it occurs soon after birth 
the lesions are usually secondary. If the second stage is completed in 
utero the disease may only become manifest in the third stage after the 
lapse of several years, usually from two to fifteen years. 

Secondary erythema of the larynx usually occurs as an accompani- 
ment of the same process in the pharynx. Practically the only phase 
of the congenital type of the disease that concerns us is the tertiary type. 
The secondary stage, if present, usually excites but little attention. 
Whether hereditary or acquired it is in the tertiary stage that relief 
usually is sought. Males are more often affected than females. It may 
occur at any age, though it is more common between the twentieth and 
fiftieth years of life. 

Gross Pathology. — The lesion is usually bilateral and appears upon 
the true and false cords as a catarrhal inflammation with hyperemic 
spots and abraded epithelial areas. Condylomata may occur on the 
epiglottis or upon the laryngeal mucous membrane, and cause consider- 
able stenosis. 

Symptoms. — Though the ulceration takes place very rapidly the pain 
is usually slight. It first appears in the form of a clear-cut, deep ulcer. 
Induration is not always present, though there may be slight thickening 
at the edges of the ulcer. Edema is not a marked feature. At the 
bottom of the ulcer the cartilage may be necrosed and the seat of suppura- 
tion; that is, perichondritis and chondritis of the larjaigeal cartilages 
may be present. The mucous membrane is hyperemic and darkly 
congested. The condition improves under the ioclides, though it may 
be temporary. Hemorrhages sometimes occur, and in rare instances 
endanger life. 

The vocal changes are unilateral paralysis (though it may be bilateral), 
with a raucous hoarseness or aphonia. Cough is in some subjects 
an early symptom. Dysphagia may or may not be present. If the syphi- 
litic lesion is located on the posterior aspect of the larynx, dysphagia is 
usually a marked symptom. 

Prognosis. — Sy])liilis of the larynx usually yields to treatment, though 
it may leave the vocal apparatus somewhat impaired as to its anatomical 
and physiological integrity. Ivife is not usually in any great danger, 
except in those cases in wliich the heniorrhngo is unnsnally severe, or in 



302 THE XOSE AXD ACCESSORY SINUSES 

those cases in which the stenosis causes suffocation. When on account 
of the suffocation it becomes necessary to perform tracheotomy the patient 
should be warned that in all probability he will have to wear a tracheal 
tube the balance of his life. 

Treatment. — The general treatment should be as for syphilis elsewhere 
in the body. Local treatment to relieve the cough or pain may become 
necessary. In case perichondritis and necrosis of the lar^mgeal carti- 
lages is present it is best to first push the iodides vigorously to diminish 
the acute pathological process, and then, if necessary, to remove the 
fragments of diseased cartilage. This may be done by direct laryn- 
goscopy, or by lar}Tigofissure (see Laryngoscopy and LarjTigofissure), 
preferably by the former, as it may become necessary to repeat the 
operation a number of times. 

In case of extreme stenosis, tracheotomy should be performed and a 
tracheal cannula introduced. 



SYPHILIS OF THE EXTERNAL EAR. 

Primary chancre of the external ear is so rare that less than half a 
dozen cases have been reported in the literature. 

The secondary manifestations may be papular, pustular, macular, 
ulcerous, or condylomatous. The entire auricle may be destroyed by 
extensive ulcerations, or it may be greatly deformed. The ear manifes- 
tations are usually secondary to a similar affection of the adjacent skin. 

Condyloma of the meatus is rare, occurring in the proportion of 
al)out 1 to every 240 cases of general syphilis (Depres and Buck). 

The course of condyloma in the external meatus is as follows : 

(a) In the beginning there is a red efHorescence of the skin, other 
symptoms being absent. 

(6) At a little later period diffuse swelling of the walls of the meatus 
occurs. 

(c) The skin begins to be slightly broken and secretion is thro^vn upon 
the surface. 

(d) Finally, warty growths, of a grayish-red color, form in the car- 
tilaginous portion of the auditory meatus, and, more rarely, in the 
osseous portion. They may be so large as to entirely block the meatus. 

(e) Pain usually develops with the appearance of the condyloma, 
especially if the skin is ulcerated. The pain is intensified by move- 
ments of the lower jaw, as the glenoid fossa is in very close relation to 
the antero-inferior wall of the meatus. Deafness and tinnitus develop 
in proportion to the degree of the meatal obstruction. Fever is 
exceptional. 

(/) Resolution may take place either with extensive destruction of 
the tissue or with little or no changes whatsoever. In some cases exu- 
berant ulceration continues for many months. Under general treat- 
ment resolution takes place quickly, and little or no scar tissue forms. 
Stricture of the meatus is rare. 



LEPROSY 303 

Diagnosis. — The diagnosis sliould be based upon the history of 
specific disease elsewliere in the body, the cliaracteristic glandular 
swelling, and the appearance of the lesion of the ear. 

Prognosis. — The prognosis of condyloma and the other secondary 
forms of syphilitic manifestation is favorable under the internal admin- 
istration of mercury and iodides. 

Gummatous formations of the external ear are usually simultaneous 
in their appearance with the same process in the middle ear. They 
may appear later as deep ulcers with elevated margins. 

Treatment. — The local treatment of the primary chancre should 
consist in cleansing the parts with black wash and then applying the 
following ointment: 

I^ — Unguent, hydrargyri, 

Lanolin aa oiv — M. 

Sig. — To be applied with cotton pads held in place with a light bandage. 

Mercury should be given internally at the same time or it may be 
rubbed into the skin in the form of blue ointment. 

Condylomata and other secondary syphilitic manifestations should 
be treated by the internal administration of mercury and the local appli- 
cation of a powder composed of equal parts of calomel and the oxide 
of zinc, which should be applied once or twice daily. 

To reduce the exuberant granulations, use a strong solution of the 
nitrate of silver. 

Gumma should be treated by the internal administration of mercury 
and the iodide of potash or iodonucleoid to the point of toleration. 



LEPROSY. 

Synonyms. — Elephantiasis grsecorum; leontiasis; satyriasis; French, 
la pette; German, der Aussatz; Norwegian, spedalskhed. 

Leprosy is a chronic infectious disease caused by the bacillus lepree, 
and is characterized by the presence of tuberculous nodules in the skin and 
mucous membranes (tuberculous leprosy), or by changes in the nerves 
(anesthetic leprosy). At first these forms may be separate, but ulti- 
mately they exist in combination. In the characteristic tuberculous form 
there are disturbances of sensation. 

It is customary to divide leprosy into two general forms, the tuberculous 
and the anesthetic, lepra tuberosa or tuberculous leprosy, and lepra 
anesthetica sen nervosa. It is also sometimes subdivided into: 
(a) Tuberculous nodular. 
(6) Non-tuberculous, 
(c) Mixed tuberculous. 

Etiology. — Geography. — In Europe it is most common in Norway, the 
Swedish, Finnish, and Russian Coasts, the East sea; then in Asia, India, 
China, Africa, Eygpt, x\byssinia, Morocco; and in America (California 
and Mexico). It is also found in Australia and the Sandwich Islands. 



304 THE NOSE AND ACCESSORY SINUSES 

The Bacillus lepr.T was discovered by Hansen, of Bergen, in 1871, 
and is universally recognized as the cause of the disease. 

Modes of Infection. — There are three possible modes of infection, viz. : 

(a) Lioculafion. — It has not been proved that leprosy is contracted by 
accidental inoculation, though it is highly probable. 

(6) Heredity. — For years it v^as thought to be transmitted, though it is 
probably not. 

(c) By Contagion. — ^The disease is contagious. The bacilli are given 
off from the nasal secretions, open sores, and the excretions of the body. 
Osier says it is probable that the bacilli may enter the l)ody in many 
ways through the mucous membranes and through the skin. Sticker 
believes that the initial lesion is in the ulcer upon the cartilaginous part 
of the nasal septum. If this is true the disease assumes greater impor- 
tance to the rhinologist and suggests the advisability of maintaining 
thorough cleanliness of the nose on the part of those associated with 
leprous patients. 

Pathology. — The Bacillus leprse has many points of resemblance to 
the tuliercle bacillus, but can be readily differentiated from it. It is 
cultivated with extreme difficulty, and, in fact, there is some doubt as to 
whether it is capable of growth on artificial media (Osier). Lepra 
tuberosa, or tuberculous leprosy, attacks chiefly the integument and the 
mucous membrane of the nose, palate, roof of the mouth, lar\aix, and 
pharynx. On the skin the first changes show themselves in the form of 
infiltration; the skin in one or more places over areas of several centi- 
meters becomes elevated and assumes a brownish-red or dull red color. 
In the region of the infiltration the sensibility disappears, partly or 
completely, and on hairy parts the hair of the afi^ected area falls out. 
On mucous membranes the lesions show themselves either as small 
patches or tubercles, or as round flat infiltrations, which become ulcerated 
and heal with cicatricial contraction. The results are often con- 
spicuous disturbances of the affected part, disappearances of the carti- 
laginous nasal septum, the soft palate, and the epiglottis. Stenosis of 
the larynx is one of the most common occurrences. Characteristic 
tubercles also often develop on the conjunctiva bulbi, especially at the 
corneal borders. The disease has a remarkably regular and progressive 
course, inasmuch as new lesions are always presenting themselves. 
The outbreaks arise with the initial eruptions. Under febrile action the 
erythematous reddening of the affected parts develops, and is soon 
followed by the formation of tubercles and nodules. At the site of the 
older lesions, usually at the time of the fresh outbreaks, changes take 
place, miliary abscesses or blebs arising, either of which may end in 
ulceration. It is deserving of mention, that at the time of these fresh 
outbreaks the lepra bacillus may be demonstrated in the blood, in which, 
at other times, it is wanting. 

Lepra Anesthetica seu Nervosa. — Anesthetic leprosy is characterized by 
sensibility and trophic disturl)ances of the skin and muscles. The new 
tissue formation, which produces the nodular growths of the tuber- 
culous form, remain in the backgroimd or are entirely wanting. The 



GLANDERS 305 

disease begins as a leprous polyneuritis. Anesthetic leprosy, in typical 
cases, has no resemblance to tuberculous leprosy. It usually begins 
with pains in the limbs, and areas of hyperesthesia, or of numbness. 
Very early bullae may form, maculae appear on the trunk and extremities, 
and, after resisting for a variable time, disappear, leaving areas of anesthe- 
sia, though anesthesia may come on independent of the maculae. Super- 
ficial nerve trunks may be large and nodular. The bullae, change to 
destructive ulcers. The fingers and toes are liable to contracture and 
necrosis. It runs a very chronic course and may not be severe in its 
results (Osier). 

Mixed tuberculated lepra is the least common form, constituting 
about one-sixth of all cases; about one-half are apparently hereditary 
and often each parent has had a different form. It begins sometimes 
with tuberculated and sometimes with non-tuberculous symptoms, but 
most frequently the latter take the lead for a few months, and then 
fever and the usual phenomena of tuberculation occur. Destruction 
of the cartilage of the nose sometimes ensues; the soft palate also 
may be destroyed by ulcerations. The balance of the symptoms are a 
compound of the other varieties. 

Prognosis. — The disease is very chronic, progressive, and probably 
incurable. The tuberculous form is destructive. The nervous form 
may not greatly impair the patient's usefulness, as in the case of the 
clergyman who continued his career for thirty years after contracting 
the disease. 

There are no specific remedies for the disease. General tonics com- 
bined with local treatment to meet the indications is all that can be 
done. 



GLANDERS. 

Synonyms. — Equinia maliasmus; malleus; malleus humidus; farcy; 
morve; farcin; rotz. 

"A contagious disease of horses and asses, but communicable to man, 
and due to the bacillus of glanders, or Bacillus mallei. It appears in 
two forms, as glanders proper, when affecting the mucous membrane, 
and as farcy when limited to the skin and lymphatic glands." (Gould's 
JJiriionary.) 

Etiology. — Originating in horses and asses, it is communicable to 
man, and from man to man. It is naturally more often foiuid in men 
engaged in occupations throwing them in contact with beasts of burden. 
While the bacillus may gain entrance through the follicles of the skin, it 
more often does so through an abraded or a wounded surface. Cases 
are reported where surgeons were infected while operating upon patients 
affected with the disease. 

Pathology. — ^There are numerous closely associated nodules of low 
grade embryonal or granulation tissue, which readily breaks down and 
suppurates. The uk-ers thus formed have undcnnincd edges, the 
20 



306 THE NOSE AND ACCESSORY SINUSES 

remnants of the preceding abscess wall. The process spreads by 
continuation, though later the process may be carried to distant parts. 
It usually appears first in the skin, and then extends to the mucous 
membrane of the nose, though it may have its origin in the mucosa. 
Baumgarten says it is a disease standing midway between abscess and 
tuberculosis. 

The nasal lesions are usually in the form of numerous closely grouped 
granulation nodules in the submucous tissue. There is a profuse prolif- 
eration of leukocytes and connective-tissue cells, with which are ad- 
mixed numerous bacilli of glanders. The proliferation continues until 
the pressure diminishes the nutrition of the mass, especially at its centre. 
Liquefaction necrosis ensues, and the nodules become abscesses. The 
outer wall soon breaks down and the contents are discharged into the 
nasal cavities. The abscesses are thus converted into open ulcers with 
undeterm'ned edges. Cross-sections of the masses before breaking down 
show them to be composed almost entirely of leukocytes, connective- 
tissue cells, and some fibrous tissue. Many Bacilli mallei are embedded 
in the masses of proliferated cells. In the acute form there are numerous 
multinuclear leukocytes in the adjoining tissue. In the chronic form 
the bone and deeper structures may be destroyed. Gangrene of the 
softer tissues may occur. 

Symptoms. — In the acute form the period of incubation is from three 
to four days. The acute symptoms often simulate rheumatism or 
typhoid fever in its initial stage. A little later the nodules appear either 
upon the skin or the nasal mucosa, according to the point of infection. 
They rapidly increase in size, as described under pathology, until (in 
nasal glanders) the purulent contents empty into the nose. The upper 
air passages are not often involved primarily in man. The progress of 
the disease is rapid, and usually leads to a fatal issue in a few days, or in 
two or three weeks. 

The chronic form is fatal in about 50 per cent, of the cases after two 
months or two years. The chronic form bears a close resemblance to 
syphilis and tuberculosis. The lymph glands of the neck are often 
much enlarged in the acute form. Chronic glanders often presents the 
symptoms of a persistent coryza. The diagnosis is difficult. It may 
be necessary to inoculate a male guinea-pig with the nasal secretions to 
clear the diagnosis. At the end of two days, in a positive case, the testicles 
of the pig are swollen and the skin of the scrotum reddened. The 
testicles continue to increase in size and finally suppin-ate. After two 
or three weeks death occurs, and the postmortem shows glanders nod- 
ules in the viscera. The use of "mallein" is highly recommended for 
diagnostic purposes. It is used in the same manner as the tuberculin 
test in tuberculosis. In all suspected cases remove a piece of the tissue 
and examine sections with the microscope; make agar cultures and inject 
into the peritoneal cavity of a guinea-pig, and watch the reactions. Also 
use injections of mallein, and watch the results. Above all, study the 
clinical phenomena, and from all the evidence obtainable arrive at a 
diagnosis. 



ACTINOMYCOSIS OF THE NOSE ' 307 

Prognosis. — The prognosis in the acute form is grave, nearly all cases 
dying in a few days. In the chronic form the mortality is about 50 per 
cent., death occurring in from two months to one or more years. 

Treatment. — In acute cases there is little hope. If seen early the 
tissue around the point of original infection should be either extensively 
cauterized or removed en masse. The wound thus created should be 
frequently bathed in a solution of the chloride of zinc (one to eight). 
All animals and horses suspected of being infected should be killed and 
their bodies burned. In chronic cases, tonics and the iodide of potash 
should be given, though no specific remedies are known. 

Glanders of the pharynx is usually an extension of the same process 
from the nose, though it may be primary in the pharynx. The nodules 
form here, as in the nose, and are attended by about the same general 
symptoms. The cervical and sublingual glands are early involved, and 
break down and suppurate, discharging externally. 

The chronic form is not attended by the same distinct phenomena, 
and is often mistaken for granular pharyngitis. The nodules are mis- 
taken for the lymphoid masses observed in chronic follicular pharyngitis, 
though, if watched long enough, they will be seen to gradually grow 
larger and larger, until serious mechanical obstruction occurs. Such a 
process in the pharynx should arouse a suspicion of glanders, and lead 
to the mallein test, or guinea-pig experiment as given under Symptoms. 

Glanders of the larynx is rare, and when present is associated with 
the same process higher up in the respiratory tract. 



ACTINOMYCOSIS OF THE NOSE. 

Synonyms. — Lumpy jaw; holdfast or wooden tongue. 

Definition. — Actinomycosis is a parasitic, infectious, and incurable 
disease, first observed in cattle and later in man. It is characterized by 
the manifestations of chronic inflammation, with or without suppuration. 
It often results in the formation of granulation tumors, especially about 
the jaw and neck. The disease is due to the presence of the ray fungus 
or actinomyces. 

Etiology. — The exciting cause is the ray fungus or actinomyces. 
The predisposing causes are an abraded mucous surface, or a diseased 
membrane. The infectious material may be carried by water or food, 
and by straws, chaff, grain, needles, etc. The fungus probably grows 
upon wheat and oats, hence, farmers should be cautioned against 
chewing wheat and oat straws, as they seem to be a prolific source of 
infection. Shoemakers occasionally contract the disease from the habit 
of holding a needle or awl in the mouth. Kissing may be the means of 
transmission from one person to another. It occurs chiefly in young 
adults. 

Pathology. — The actinomyces were formerly thought to be mold fungi, 
but Bostroem, in 1885, proved by cultivation that they are a variety of 
cladothrix, belonging to the schizomycetes. The diseased mass is 



308 THE XOSE AXD ACCESSORY SIXUSES 

made up of granulation tissue, which, except for the ray fungus, would be 
mistaken for a round-cell sarcoma. Epithelioid elements and giant 
cells are also sometimes present. In the granular mass, or in the pus, 
the fungus itself appears under the form of small, yellow, bro^^^l, or 
even green masses, about the size of a pinhead, which, upon micro- 
scopic examination, are found to be composed of a central interwoven 
mass of threads, from which radiate club-shaped ended rays. In man 
the clubbed bodies are frequently absent (Senn.) The histological 
lesions are alike in the actinomycotic nodule, and m the tuberculous 
follicle, only the germ boily differs. Water, or a weak solution of 
sodium chloride, causes the rays to swell enormously and lose their 
shape; ether and chloroform have no action upon them. The gross 
pathological anatomy of the disease is everywhere associated with 
chronic indurations, with softening and liquefaction, and with resulting 
sinuses and cysts. The head, neck, and especially the jaw, and the 
cervical fascia are the sites of the disease. In the cervical fascia, the 
disease gives the neck a brawny hardness. The lymphatic glands are 
not, as a rule, extensively affected. In the ox the tongue is often affected. 

The lesion may be self-limited, as in tuberculosis, by cicatricial en- 
velopment. 

The kernel-like nodules are usually multiple. They may coalesce, 
and the resulting masses may "heal out." When bone tissue is affected, 
there is central destruction, while peripherally there is hyperplasia. 



ACTINOMYCOSIS OF THE PHARYNX AND TONSILS. 

Pathology. — Implantation of the ray fungus leads to the develop- 
ment of granulation tumors, similar to localized tuberculous inflammation. 
Nodules of small round cells, containing giant and epithelioid cells, 
are sometimes found. Differential stains help to show them. Follow- 
ing this there is considerable reaction and proliferation of the tissue 
elements, somewhat resembling sarcoma. The proliferation is followed 
by a chronic and intractable suppuration and sinus formation. It is 
questioned as to whether ray fungus is pyogenic, or whether the pus 
present is due to mixed infection. Infection may be transferred by both 
the lymphatics and bloodvessels, proloably more frequently by the latter. 

Symptoms. — The symptoms vary according to the part affected. The 
afl'ection is chronic, but occasionally rims a rapid course. The granula- 
tion tissue is abundant and the mass resembles a tumor. Previous to 
suppuration it is quite firm, and if progressing rapidly it is surrounded by 
diffuse edema. Pain and tenderness are rarely present. "\Mien suppura- 
tion occurs the mass increases rapidly in size. 

The frequency of occurrence in different parts of the bofly in 500 cases, 
as collected by Poucet and Berard, is as follows: Head and lungs, 55 per 
cent. ; thorax and hmgs, 20 per cent. ; abdomen, 20 per cent. ; other parts, 5 
per cent. In France the face and neck were affected in 85 per cent, of 
the 66 cases reported. 



ACTINOMYCOSIS OF THE PHARYNX AND TONSILS 309 

The symptoms may be grouped in two classes : (a) Those referable to 
local tumefaction and purulent discharge, and (b) those referable to the 
general intoxication of the system by the suppurative products, or their 
metastatic spread, and which do not differ from those of chronic 
suppuration. The local symptoms are of slow development, and are 
largely those of gradual mechanical interference of the pharyngeal 
function. At the site, or sites, of inoculation a small rounded and 
reddish elevation appears, attended by the usual subjective annoyances 
of an attending pharpigitis. The adjacent tissues become swollen and 
tumefied, and the evidences of an acute inflammation soon change to the 
more permanent engorgement and solidity of a chronic condition. The 
swelling is irregular, but well outlined, firm to probe palpation, 
and not oversensitive, and slowly increases in size. Suppuration and 
the formation of angry-looking sinuses follow, from which issues 
a purulent discharge, in which are the small yellowish pellets, or 
masses, composed largely of the typical ray fungus. The discharge is 
persistent, and the sinuses extend deeply and produce extensive tissue 
destruction. The spread of the process does not, as a rule, occur, and 
it shows a tendency, if it occurs elsewhere, to do so as an isolated swelling 
rather than as a connected overgrowth from the original pharyngeal focus. 
Pain is a variable quantity, and depends largely upon the seat and 
extent of the peculiar swelling. Usually there is more or less continuous, 
heavy aching felt locally, and this may, at times, be eased or intensified 
into acute distress. Fetor of the breath and gastric disturbances from 
the purulent discharge are often present. The appearance of the 
disease elsewhere by metastasis is to be expected, especially in the lungs 
or the alimentary tract, though no portion of the body is free from 
possible invasion. The systemic symptoms may be severe or slight, 
according to the degree of involvement and the exit of the suppurative 
products, and do not differ in their character from those usually observed 
in any other suppurative condition. Death occurs from slow exhaustion, 
or through some intercurrent affection or complication (Kyle). 
Diagnosis. — Actinomycosis should be differentiated from: 

(a) Sarcoma. 

(6) Tuberculous infection. 

(c) Carcinoma (of the tongue). 

(d) Syphilis. 

(e) Epulis (in jaw). 
(/) Lupus. 

It is, perhaps, impossible to make a positive clinical diagnosis of 
actinomycosis. A microscopic examination showing the ray fungus, 
or a guinea-pig inoculation, may be necessary to establish it. The 
presence of the yellowish particles in the pus discharge is quite 
characteristic, though not conclusive. Actinomycosis is probably not as 
rare as is generally supposed, as it is occasionally mistakenly diagnos- 
ticated as sarcoma, carcinoma, osteomyelitis, syphilis, etc. 

(a) Sarcoma is histologically quite similar to actinomycosis. A 
careful microscopic examination will, however, in actinomycosis show 



310 THE NOSE AND ACCESSORY SIXUSES 

the presence of the ray fungus and some giant cells. Sarcoma does not 
break down and sup})urate so early. Both occur quite frequently in 
the young. 

(6) Tuberculous disease is attended_by an enlargement of the regional 
lymphatics. In actinomycosis the regional glands are not enlarged. 
An examination of the sputum or a guinea-pig inoculation will show the 
tubercle bacilli if present. 

((') Carcinoma of the tongue is usually found nearer the base, 
whereas actinomycosis affects the tip. Then, too, in carcinoma there 
are lancinating pains, ulceration, and cachexia. 

{(l) Syphilis, in the gummatous stage, is more amenable to the iodides. 
The general history of the case is also an aid in the differential diagnosis. 
Acute progressive actinomycosis may very strikingly resemble acute 
phlegmonous inflammation and osteomyelitis. 

Treatment. — The iodides are excellent in recent cases. In old cases 
in which there is a mixed infection, it is less efficient. The remedy 
should be pushed to pronounced iodism. The injection of a 5 per cent, 
solution of the permanganate of potash into the cysts, when present, has 
proved of advantage. Cauterization of the skin and soft parts with the 
solid stick of silver nitrate is a valuable aid in those cases in which there 
is a fistula and suppuration. Gautier reports excellent results from the 
injection of a 10 per cent, solution of the iodide of potash into the mass. 
Needles connected with both the positive and negative poles may be in- 
serted into the tumor, and 50 milliamperes of current are passed through it. 
Every minute a few drops of the iodide of potash solution should be injected 
until a total of 20 minims is used. The electric current decomposes the 
iodide solution into nascent iodine and potash. The chemicals thus 
liberated in the actinomycotic tissue exert a favorable influence upon 
the further progress of the disease. A general anesthestic should be 
administered for the injections. Repeat the injection and electric current 
in eight days. 

The surgical treatment of actinomycosis consists in anything from 
simple incision to the complete removal of the entire mass. The disease is 
best suited to surgical treatment before the stage of suppuration and 
extension to the regional glands. When it has progressed thus far it is 
no longer simple actinomycosis, as it is now complicated by a mixed 
or streptococcal and staphylococcal infection. A simple incision is some- 
times effectual, as is, indeed, spontaneous rupture. Should excision be 
I'csorted to, it should be complete, and followed by the thermocautery, to 
])revent the spread of infection to the exposed lymph spaces. After 
suppuration is established, treat as for tuberculosis, i. e., curette and 
])ack with iodoform gauze. 

The disease seems to be self-limited by the formation of a capsule of 
connective tissue, and by spontaneous rupture. 

Iodide of potash or iodonucleoid are probably the most reliable internal 
remedies. 



ACTINOMYCOSIS OF THE MIDDLE EAR 311 



ACTINOMYCOSIS OF THE MIDDLE EAR. 

Actinomycosis of the middle ear is very rare, and the only literature 
on the subject is the clinical report of a case by Zaufal, of Prague, and a 
more extended report of the same case, with the postmortem findings, 
by J. C. Beck, of Chicago, and a second case of Mojocchi, of Italy. 
The clinical aspect of Beck's case was as follows: Carl J., fifty-four years 
old, a farmer, always healthy, with a negative history of aural, nasal, and 
pharyngeal disease, until six months previous to the examination. At 
that time there was a swelling back of the left ear and left side of the neck. 
The swelling, at first hard, soon softened, and was never painful. Later 
a third swelling appeared on the left side of the neck, which opened 
and discharged pus through a fistula. At this time the hearing became 
defective. The functional tests of hearing showed a negative Rinne, 
and Weber lateralizing to the left side, thus showing middle-ear disease. 
There was no secretion from the external auditory meatus, but the post- 
superior wall, at the fundus, sagged as in mastoiditis. A swelling the 
size of the palm of the hand was situated over the mastoid and the region 
posterior and inferior to it. It did not fluctuate. A smaller swelling, 
more anteriorly, had a fistulous opening in the region of the tip of the 
mastoid process. Compression expelled a greenish pus, containing 
small granules. The subsequent microscopic findings showed the ray 
fungus of actinomycosis in abundance. A radical mastoid operation 
was performed, but the healing process was unsatisfactory. Five weeks 
later the patient died from an intracranial hemorrhage, due to the ulcera- 
tion of a large bloodvessel in the region of the actinomycotic process. The 
postmortem was held by Chiari, who found the muscles of the neck on 
the left side and the upper cervical vertebra infiltrated with pus contain- 
ing yellowish particles. There was no suppurative process in the cavum 
tympani. A fistulous tract was traced with a fine probe from the cavum 
tympani toward the exposed incisure mastoidei. The left sigmoid 
sinus was filled with a substance of a light yellow color, and was adherent. 
The cervical glands on the left side were enlarged, and cross-sections 
showed whitish discolorations. Sections of the tonsils and the contents 
of the lacunae were negative as to actinomycosis. The ulcerated artery 
causing the fatal hemorrhage was examined microscopically by Beck, 
who found the ray fungi in its walls. This is the first reported case 
in which the ray fungus has been found in the wall of a bloodvessel. 

The only other case of actinomycosis of the middle ear on record 
is reported by Majocchi, of Italy. In his case, the primary infection 
was of the lung, the infection of the ear probably occurring during a fit 
of coughing. 



PART II. 
THE PHARYNX AND FAUCES. 



CHAPTER XVII. 

DISEASES OF THE EPIPHARYNX AND BASE OF THE TONGUE. 

ACUTE LACUNAR INFLAMMATION OF THE PHARYNGEAL TONSIL. 

According to Felix Peltesohn, the "pharyngeal tonsil consists of six 
fairly symmetrical folds separated by deep furrows running in a sagittal 
direction, which may be separated from each other like the leaves of a 
book. Posteriorly and sometimes anteriorly there is a curved fold 
connecting all of them. In the middle there is a deep fissure — the 
recessus medius — to which, in some instances, a blind canal leads, and 
which was formerly erroneously described as an independent structure, 
the bursa pharyngea, known as Thornwaldt's disease." 

Bickel, in defining a tonsil, says it is characterized (a) by its well- 
defined shape, (b) by a diffused infiltration of lymph cells and follicles, 
(c) by crypts or lacunae, that is, mucous pockets lined with epithelium, 
around which the lymphatic tissue is arranged. 

If we take his definition literally only the pharyngeal and faucial 
tonsils are real tonsils, as the lymphoid tissue in the other parts of the 
so-called "tonsillar ring" do not have crypts or lacunea. 

Symptoms. — Angina lacunaris of the pharyngeal tonsil, like that of 
the faucial tonsils, is an infectious disease. It is rarely recognized as 
such by physicians on account of its hidden location back of the post- 
nares and the soft palate. It may be seen, however, with a postnasal 
mirror. The crypts or lacunae will be seen filled with a yellowish-white 
exudate, composed of epithelium, inflammatory exudate, and pus cocci. 
An inexperienced physician might easily arrive at the erroneous con- 
clusion that the spots were "ulcers;" indeed, the same error has often 
been made concerning the faucial tonsils. During the acute stage the 
pharyngeal tonsils are red and swollen. 

That the disease is infectious is shown by the clinical data — 
namely, the initial chill, the rise of temperature, the prostration, swelling 
of the spleen and cervical glands, and the prolonged convalescence. 
Microscopic examination reveals a great variety of infectious germs. 



314 THE PHARYXX AXD FAUCES 

The secretion is often so fluid as to ooze out of the crypts and coalesce 
with that of an adjoining crypt. 

Acute lacunar inflammation of the phar^aigeal tonsil does not occur as 
often as acute lacimar inflammation of the faucial tonsils. This is 
probably due, in part, to the filtering function of the vibrissse and moist 
mucous membrane of the nose. 

It occurs most often during the first twenty years of life, because the 
lymphoid (adenoid) tissue is more developed and more sensitive during 
this period of life. It has a strong tendency to recurrence. The nose 
becomes obstructed and there is pain upon swallowing, but it is not 
definitely located as in diseased faucial tonsils. The voice becomes nasal, 
or void of resonance, as in hypertrophy of adenoids. The glands at the 
angle of the jaw and in the deep cervical region are swollen and painful 
upon pressure. 

The fever is cyclical, being less in mornings and greater at night. It 
continues for several days and leaves the patient quite exhausted. The 
pharyngeal tonsils continue swollen for some time, perhaps permanently 
after the fever subsides, and causes more or less nasal obstruction. 

To one not accustomed to examining the epipharynx the following 
suggestion by Peltesolin is of great value in making a diagnosis: "If 
the tongue is draA\Ti so far forward that one can look behind the palatine 
arch, then one can see the salpingopharyngeal fold, the so-called 'lateral 
column,' deeply reddened and studded with yellow follicles." This 
condition is characteristic of angina lacunaris of the pharyngeal tonsil. 
The tongue should be held with a tongue depressor and pulled forward 
as in the examination of the lar}iix. As the space between the soft 
palate and the posterior phar\Tigeal wall is still quite wide in young 
people, the postrhinoscopic examination is easily made. 

Patients frequently complain of a feeling of fuhiess and pressure in 
the ears, but do not often have active inflammation of the middle ear. 
The nasal secretions are acrid, and often cause nasolabial excoriations. 

Diagnosis. — (a) Initial infective fever, chill, and cyclical fever. 

(6) Obstructed nasal passages and non-resonant voice. 

(c) Most important of all, the red and swollen follicles of the "lateral 
colunm" (follicles just back of the posterior faucial pillars), from which 
a yellowish secretion is exuding. 

These signs, together with the postrhinoscopic examination, will lead 
to a correct diagnosis. 

Treatment. — Experience teaches that during the course of the acute 
or febrile stage local applications irritate and should not be attempted; 
even gargles should not be used. The patient should be put in bed and 
kept there until the disappearance of the fever, or even a few days longer, 
as the prostration is pronounced. He may be given pieces of ice to hold 
in the mouth, as it seems to afford some relief. Only a bedridden diet 
should be allowed. 

After complete recovery the adenoid masses, be they large or small, 
should be thoroughly removed with a curette, otherwise recurrence 
will likely take ])lace. In adults these recurrences are characterized 



ADENOIDS 315 

by the formation of crusts in the epipharynx. These crusts, therefore, 
indicate the need of an adenoid operation. 



ADENOIDS. 

Synonyms. — Adenoid vegetations; pharyngeal adenoids; pharyngeal 
tonsils; epipharyngeal tonsils. 

Definition. — Adenoids are hypertrophied lymph glands which nor- 
mally exist in the epipharyngeal space. They are chiefly located on the 
superior and posterior walls of the epipharynx, though they may extend 
into the fossae of Rosenmiiller and to the mouth of the Eustachian tubes 
(tuba auditiva Eustachii). Trautmann divides the adenoid pads into 
two groups, an anterior and a posterior one. 

The edges of the walls of the recessus medius sometimes become 
agglutinated during acute inflammatory processes, and thus convert the 
groove into a sinus, which becomes infected and continually discharges 
its secretions into the pharynx (Thornwaldt's Disease). 

Etiology. — The chief cause of adenoids is the irritation and inflamma- 
tion occurring in the epipharynx during attacks of one of the exanthem- 
atous fevers. It is a well-known pathological law that the lymphatic 
structures of children become enlarged or hypertrophied in response to 
bacterial stimulation, whereas the same stimulation in adults does not 
cause lymphoid hypertrophy to a corresponding degree. 

As the exanthematous fevers occur chiefly n early childhood while 
the special susceptibility exists, it is but natural to find adenoids most 
frequently during this period of life. 

According to the statistics on this subject by McBride and Turner, 
adenoids are most frequently found between the sixth and the fifteenth 
years of life, though they may occur at any period. In children who 
were otherwise normal it has been variously estimated that they were 
present in from 1 to 9 per cent, of all cases examined. In deaf-mutes 
they are present in from 50 to 73 per cent, of all cases examined. 

While it cannot be said that adenoids are hereditary, they are, never- 
theless, in many instances a family characteristic, perhaps on account 
of a similar environment and similar anatomical conformations pre- 
disposing to infection of the epipharyngeal tissues. 

Climate probably plays but a small part in the causation of adenoids, 
though it should be said that a cold, damp, changeable climate subjects 
the mucosa, as well as the general system, to repeated shocks which lower 
the vital energy of the body and render it an easy prey to microbic 
irritations within the epipharynx. 

Pathology. — The distribution of adenoid tissue in the epipharynx 
is chiefly on the upper and posterior walls, though it may extend to the 
fossae of Rosenmiiller and to the orifices of the Eustachian tubes. They 
are composed of lymphoid tissue enmeshed in a definite though com- 
paratively delicate reticulum of fibrous connective tissue. The essential 
pathology of adenoids consists in the hypertrophy of the lymphoid tissue 



316 'I^JJ^' PlfAr^VW AXD FAUCES 

of the e])i])liarviix, which is iionnally present tliere. There are other 
pathological changes whicli are best described by ^NIcBride and Turner 
in their classical paper on " Nasophar\nigeal Adenoids; A Clinical and 
Pathological Study," from which I quote as follows: 

"We may assume the pharpigeal tonsil to be a peripherally placed 
lymphatic gland, from which efferent ducts pass to the nearest glands in 
the cervical chain. like similar glands elsewhere, the phar\aigeal 
adenoid tissue consists of a fibrous connective-tissue framework, 
supporting masses of lymphoid cells, but owing to its peripheral position 
it differs from the more deeply placed lym})hatic glands in having an 
epithelial covering upon its free surface. The supporting framework 
consists of fibrous septa passing through the substance of the gland, 
from which a very delicate connective-tissue network ramifies in all 
directions toward the surface. It carries in it the bloodvessels and the 
lymphatics, while here and there, lying in clusters in the septa, may be 
seen many nuicous glands whose ducts open on the surface. In the meshes 
of the delicate network lie masses of leukocytes or lymphoid cells, con- 
stituting the lymphoid tissue which forms the main bulk of this tonsil, 
(iroups of these cells are specially differentiated in the form of more or 
less rounded or oval-shaped areas, having centres of a pale appear- 
ance, while their margins are more darkly colored. These areas are 
the follicles or germ centres of Goodsir. Covering the free surface of 
this tonsil, and dipping do^^^l into its recesses and crypts, is a layer of 
ciliated epithelium, continuous with that lining the respiratory part of 
the interior of the nose and the adjacent mucous membrane of the epi- 
pharynx. The epithelium consists of more than one layer of cells, the 
superficial ciliated cells being columnar in type, while the deeper cells 
forming two or three layers are smaller, and rest upon a well-definefl 
basement membrane. 

The Epithelium. — "The normal epithelial covering undergoes a certain 
amount of variation, as might be expected when a growth of this kind, 
itself subject to variations in size, fills to a varying extent a cavity 
like the epiphar\aix, more or less completely surrounded by firmly 
resisting bony walls, and whose size is intermittently changing through 
the movements of the soft palate which constitutes its floor. The 
epithelium is not found to be always of a imiform thickness. While 
preserving its ciliated columnar type its thickness is seen to vary in 
parts, so that the lining of some of the crypts presents an irregular 
outline. In a certain number, however, of the preparations examined 
there is a marked change in the character of the epithelium, becoming 
of the stratified squamous variety and of a very considerable thickness. 
This change and thickness is not general, but is confined to certain areas 
on the surface of the hypertrophy. It is not normal to this part of the 
upper respiratory tract, because the whole of the mucous membrane of 
the pharynx as low as the level of the lower border of the soft palate is 
covered with ciliated epithelium, and it is from within the area so covered 
that the ej)ithelium thus altered and thickened shows that the.se changes 
occur among the youngest of the patients examined. With two exceptions 



ADENOIDS 317 

at the age of twelve, all were under ten years of age, and in two cases 
where the thickenmg was most marked the patients were only four years old. 
On the other hand, in the sections of the growths removed from patients 
of fifteen years and upward, with one exception no thickening of the 
epithelium was observed, sO that we are naturally led to the conclusion 
that this change in the epithelial covering is not one necessarily dependent 
upon the prolonged existence of the hypertrophy. Occurring, as the 
examination shows that it does, in the younger patients, it is more 
reasonable to conclude that it is due to pressure of the growth upon the 
walls in the smaller epipharynx of the young child. Its presence on the 
surface and in patches only and less frequendy in the crypts are further 
points in favor of such a view being held. Unfortunately, we are unable 
to say whether, in those cases in which the epithelium has changed to 
the pavement type, the adenoid masses were large and more or less 
completely filled the epipharynx. Such a change in the type of the 
epithelium as noted here has been observed before, as the residt of 
pressure, and is a point of some histological interest. The pressure to 
which these growths is subject is intermittent, and is caused chiefly by 
the elevation of the soft palate in the act of deglutition, pressing the 
soft, pliant mass upward against the walls of the space, and releasing it 
again when the act is completed. 

The Fibrous and Lymphoid Tissues. — "A considerable variation was 
found to exist in the relative proportion of lymphoid and fibrous tissue in 
the growths examined; and we have endeavored, by a comparison of the 
appearances observed in patients of different ages, to seek some expla- 
nation of the gradual disappearance or shrinking which takes place in the 
hypertrophied adenoid tissue in course of time. An overgrowth of the 
fibrous tissue takes place. This appears to commence around the blood- 
vessels by a process of perivascular sclerosis; at any rate, it is in the 
neighborhood of these vessels that the fibrous thickening is most evident. 
If an area be examined in which this change is taking place, some of the 
bloodvessels present a normal appearance, others again show distinct 
thickening of their walls in concentric rings, with diminution in the size 
of the lumen. One specimen shows, in a remarkable manner, many of 
the bloodvessels completely obliterated, partly owing to the great thick- 
ening of the walls and partly due in all probability to the contraction 
of the fibrous tissue outside. Round the vessels there is fibrous tissue 
formation, varying both in amount and in density, according to the 
stage of development that has been reached; in this way the lymphoid 
tissue becomes gradually invaded and areas of cells are isolated by the 
process. There can be no doubt that it is by fibrous-tissue formation 
that the gradual shrinking of the adenoid mass occurs. In order to 
ascertain what relation sucli a process might bear to the age of the 
patient, a comparative study of the various growths was made with tliis 
end in view. 

"PVom such an analysis it would appear that a development of fibrous 
tissue takes place in the substance of the adenoid hypertrophy, commenc- 
ing round tlic bloodvessels iuvading the lymphoid tissue, and replacing 



318 



Tllb: I'JIARYNX AXD FAUCES 



it. This process, however, is independent of the age of the patient, 
and is not one that necessarily commences at or after puberty, but may 
occur at all ages, and be even more marked in the very young child than 
in the adult. Here again our experience coincides with that of M. 
Brindel. The practical deduction to be drawn from these facts is, 
that we cannot say in any given case that a growth may be satisfactorily 
left to disappear per se. It may or it may not do so at some early period, 
but because a })ationt is approaching puberty or adult life it does not 
follow that the adenoid hypertrophy will in a short time cease to exist. As 
we have already stated, such growths do, in certain cases, disappear at 
puberty, but it is quite possible that here a purely physical, as opposed 
to purely histological, explanation may be called to our aid. Obviously, 
in the small ('j)ipharynx of the child the growth may entirely fill the space, 
while, as adult life is approached, a free space will be left between the 

adenoid hypertrophy and the palate. 
In the former case, each respiration 
will exercise suction upon the mass, 
while in the latter this physical effect 
will be much diminished, if not quite 
absent." 

The foregoing findings should be 
given wide circulation among the 
medical profession, as physicians 
too often advise their patients "to 
wait for puberty," as the adenoids 
will "shrink" at that time. "Wait- 
ing" for adenoids to "shrink" is al- 
ways a foolish and dangerous thing. 
While waiting, the attending inflam- 
mation is ever progressing, and may, 
and actually does in 66 per cent, 
of all cases, invade the Eustachian 
tubes and middle ear. Furthermore, 
it is shown that the atrophy does 
not occur more after puberty than at a younger age; indeed, that the 
atrophy is independent of the age of the adenoid patient. Why wait, 
therefore, for a process of shrinking which has no definite period of 
occurrence. 

Symptoms. — The symptoms of adenoids may be divided into: 
(a) Objective. 
(/;) Subjective. 
((•) Collateral. 
Objective Symptoms. — The ol)jectivc symptoms are those appreciated 
through the special senses of the attending surgeon. 

By inspection he notes the open mouth, thick, short upper lip (Fig. 204), 
the comjjaratively expressionless countenance, and with the lar\aigeal 
mirror he finds the epipharynx to be more or less filled with the adenoid 
masses. 




ADENOIDS 



319 



By the sense of touch he distinguishes a gelatinous, worm-hke mass in 
the epiphaiynx. The finger should be anointed with vaseline before 
it is introduced into the epipharynx, so as to reduce its frictional qualities 
to the minimum. Even then great care should be exercised lest the deli- 
cate mucous membrane of the epipharynx be injured. In spite of these 
precautions the finger is often streaked with blood upon its removal. I 
find the digital examination of more value than the one with the mirror in 
a majority of the cases. It need occupy but a few moments for its per- 
formance. . 

The examining surgeon should stand in front of and to the right of 
his patient, encircling his head with the left hand and arm to steady 
it, while the index finger of the right hand is introduced into the 



Fig. 205 




epipharynx. McBride and Turner have suggested that if the thumb 
of the examiner is just outside the patient's right cheek, he can 
prevent biting by pressing the thumb against his cheek wall. The soft 
tissues being thus forced between the patient's teeth, he cannot bite the 
examiner's finger. 

The faulty development of the chest walls is also characteristic of 
mouth breathing in children (Figs. 219 and 220). 

The sense of smell should also be utilized in the examination for 
adenoids, as a fetid breath is sometimes present. 

The auditory sense should also be utilized in the diagnosis, as the 
patient's voice is often characteristic. The articulation is muffled and 
the resonance of the voice is diminished. 



320 THE PJIARYXX AXD FAUCES 

The Subjective Symptoms. — Xi(jlit-time restlessness is a prominent 
syniptoni, the patient often throwing the covers off during the uncon- 
scious rolHng and tossing which is so characteristic of mouth breathers. 
Night terrors are also frequently complained of, especially if the child is 
troubled with enuresis. 1 have often noted that night terrors or horrible 
dreams immediately precede nocturnal urination. 

Night terrors are not present in all cases, perhaps not in more than 
one-third of them, and is in all probability due to reflex causes and to an 
excess of the half-way products of metabolism. These dreams are often 
of the most terrible nature, and are often indelibly impressed upon the 
memory. 

Daijfxmc restlessness is also a characteristic sign of adenoids. The 
child is fretful and j)eevish, or is inclined to turn from one amusement to 
another, or from an imposed duty to play. 

Aprosexia or difficult attention, first described by Guye, of Amsterdam, 
is very often present. The child has difficulty in applying himself 
continuously to his studies or other tasks set before him. He has fits 
of abstraction. 1 once knew^ a boy in school who was afflicted wdth 
ideal abstraction, though he had a fairly good mind. During one of 
these "spells" his teacher shook him vigorously by the shoulders, and 
the boy said, "I ain't doin' nothin'." Whereupon his teacher replied, 
"That's just the trouble; get busy and do something." 

Taste and smell are sometimes impaired, which is not strange, in view 
of the fact that the sense of smell and of taste are so intimately associated, 
and the epiphar}aix is blocked with adenoids, thus compelling the child 
to breath through its mouth. 

The bi'cath is often fetid, irom the decomposition of the retained secre- 
tions and from the disordered stomach so often complained of. 

Bilious attacks or a disordered stomach sometimes complicate the 
case. 

An elevated temperature is not an uncommon symptom, as the adenoid 
growth is frequently the seat of a lacunar or catarrhal inflammation. 

Epipharyngeal catarrh is an almost constant accompaniment of 
adenoids. Indeed, it is doubtful if adenoids of any considerable size 
are present without a concomitant chronic epipharyngitis, or w^hat is 
commonly spoken of as a pharjaigeal catarrh. This symptom or 
complication is one of the strongest arguments in favor of the removal 
of adenoids, as the catarrhal inflannnation has a tendency to extend 
by contimiity of tissue into the Eustachian tube and middle ear. In case 
of an acute infectious exacerbation the middle ear and even the mastoid 
cells are liable to Ix^come involved. 

Collateral Symptoms. — Defective speech is a symptom of considerable 
diagnostic and economic importance. The voice is muffled and articu- 
lation is impei-fect. The nvsonance, or timbre, of the voice is greatly 
impaired. 

Ear complications are present in a majority of the cases. According 
to ]McBri(le and Turner, who analyzed 307 cases, 255 had ear involve- 
ment of one kind or another. Of the 255 cases, 144 were suppurative 



ADENOIDS 321 

and 111 were more or less deaf with non-suppurative ear disease. 
They say: "We have more than once noticed in children (affected with 
adenoids) suffering from non-suppurating otitis media that in those 
in whom the membrana tympani had assumed an appearance which 
can but be likened to that of ground glass, especially when there was 
a permanent pinkish tinge, the prognosis as to improvement by subse- 
quent treatment was not good, sometimes positively bad." 

It appears, therefore, that the ear complications, whether of the 
suppurative or non-suppurative type, may be serious. 

Diagnosis. — The diagnosis in most cases is so obvious that it scarcely 
warrants special mention. There are exceptional cases, however, in 
which an error in this regard may be made. It may be stated as an 
almost universal rule that when the tonsils are hypertrophied adenoids 
are also present. Conversely, it cannot be said that when adenoids are 
present the tonsils are also hypertrophied, as statistics show that only 
30 per cent, of the cases with adenoids had enlargement of the tonsils. 
It appears that the adenoids most easily undergo enlargement, the 
tonsils next, and the lingual less than either of the other lymphatic 
structures composing Waldeyer's ring. 

The fringe of the adenoids seen on the posterior wall of the pharynx, 
just below the line of the soft palate, is quite characteristic of adenoids. 
When these nodules are present in a child, I am quite certain of the 
diagnosis, even without further examination, though I do not recommend 
that the examination should stop here. 

The epipharyngeal mirror should be used, when possible, to enable 
the surgeon to see the adenoids and their distribution. In many cases 
this method of examination cannot be adopted on account of the reflex 
closure of the palatal muscles against the posterior pharyngeal wall. 

When the mirror cannot be used the index finger of the right hand 
should be introduced through the mouth into the epipharynx for the 
purpose of detecting the gelatinous worm-like mass of adenoid tissue. 

It is not sufficient to merely determine the presence of a large adenoid 
cushion in the vault, or on the superior posterior wall of the epipharynx, 
but the examiner should determine whether the fossae of Rosenmiiller 
or the tubal orifices are covered by the growths. Adenoids are not 
removed merely because they are enlarged, but because of the epipharyn- 
gitis which almost always attends them and on account of their presence 
in the fossae of Rosenmiiller and the Eustachian orifices, even though they 
be small. 

Fibrous tumors of the epipharynx are sharply defined and are dense 
in texture, whereas adenoids are not sharply defined and are soft in 
texture, hence there need be no difficulty in making a differential diag- 
nosis. 

Malignant tumors of tlie epipharynx can scarcely be mistaken for 
adenoids if an ordinarily careful examination is made. The hemorrhage, 
cachexia, and other symptoms readily distinguish tlie cancerous growths. 

Tuherculous and syphilitic granulomata rarely simulate adenoid 
growths. Carel has reported two cases of tertiary syphilis, and 



322 



77/A' PHARYXX AXD FAUCES 



Lcniioyez a case of tuhcrculosis of the epipharvnx, which closely 
resembled, in o;eiieral symptomatology, adenoid growths. 

Prognosis. — The j^rognosis from the standpoint of the mentality of the 
patient varies from slight retardation of mental development to an almost 
complete arrest of it. The improvement in the mental growth after oper- 
ation is often marvellous, provided the operation is performed during the 
natural period for such development, e. g., during infancy and childhood. 




Brandegee's adenoid forceps. 

If the removal of the growth is delayed imtil the individual has prac- 
tically attained full growth, the mind will rarely develop to any consider- 
able degree. 

The general health rarely improves diu'ing infancy and childhood so 
long as marked adenoids remain. If, however, they are removed, the 
blood becomes red from free oxygenation and all the vital energies are 
quickened and increased. 

The "facial or adenoid expression" improves somewhat Avith advancing 
years, though it often remains as a permanent disfigurement through 
life. If the adenoids are removed sufficiently early in life the "adenoid 
expression" often disappears, or its further development is prevented. 

The removal of adenoids often prevents serious car complications, 
improves the general health, and heautifies the face. 




\uliff's aileiioid forceps. 



Treatment. — There is but one tn^atmcnt worthy of the name, and that 
is the surgical removal of the growths. Astringent applications have been 
and are still advocatetl by some writers, but in my opinion their use is 
but a means to postpone the day when their removal must take place. I 
can conceive how a cong(\stion and inflammation of the lymphoid masses 
might be relieved and greatly improved by the local use of alkaline and 



ADENOIDS 



323 



astringent washes, but when true hypertrophy has occurred the curette or 
forceps offer the best means of treatment. 

Adenoids may be removed with the Meyer ring curette through the 
nose, though this is an almost obsolete method. A more rational and 
effective method is with a Gottstein curette or some modification of it. 
During the last few years I have depended more and more upon an 
adenoid forceps of the Brandegee pattern. 

Fig. 209 




The correct position of the patient under general anesthesia for the removal of adenoids 
and tonsils. 

Technique. — ^The following technique may be employed for simple 
adenectomy, while in combined adenectomy and tonsillectomy ether 
anesthesia is preferable (Figs. 209 and 210). 

(a) Nitrous oxide anesthesia. 

(6) The removal of the adenoids with the Brandegee forceps : The 
instrument is introduced, closed, through the mouth in much the 
same manner as is used in intro- 
ducing the curette ; that is, the 
curved tips are turned behind the 
posterior pillar of the patient's 
right side and then passed up- 
ward behind the soft palate and 
rotated toward the median line 
as they engage behind the soft 
palate. The biting tips are then 
opened and forced upward against 
the vault of the epiphar}'nx, the 
handles meanwhile l)eing held 
against the upper teeth. Having Furguson-Pyncium mouth gag. 

forced the tip against the vault, they 

should l)e pushed backward against tlie jxwtcrior wall of the epipharynx. 
The blatles should then be closed, care being taken to hold the 




324 TJIK PHARYXX AXD FAUCES 

handles against the upper teeth. The rockhig motion used with the 
curette is to be studiously avoided when using the forceps. Should 
the handle of the instrument be lowered while the blades are open in 
the epipharj-nx, they will engage the posterior end of the septum and 
injure it. 

Having closed the forceps, it should be removed with a do\Miward 
pull, bringing the adenoid mass out between the cutting blades. The 
instrument may be introduced more than once if necessary. 

((') Introduce the curette (Fig. 211) in the same manner. When 
introduced use pressure in an upward and backward direction, and 
move the handle of the instrument up and do\Mi between the upper and 
lower teeth. The soft palate should be the imaginary fulcrum during 
these movements. By thus manipulating of the curette both the superior 
and posterior walls are scraped free of the adenoid pads. The instru- 
ment should be introduced between the Eustachian prominences, so as 
to include the entire width of the growth. 

(d) Introduce the right index finger into the epiphar^aix and rub 
away any shreds and remnants of adenoid tissue which may remain. Also 
explore Rosenmiiller's fossse with the finger tip and remove the adenoid 
cushion from them should it be present. 




Boeckmanu's adei 



(e) The patient's head should then be held over the fountain cuspidor 
until bleeding stops or consciousness is restored. 

The operation is done with the patient in the sitting posture, preferably 
in the lap of an assistant. He is wrapped with a sheet, which is pinned 
tightly about him to prevent his arms getting in the way during anesthesia. 

I sometimes do the operation without a general anesthetic if the 
patient is old enough to submit without resistance. The pain is not 
great and the danger from an anesthetic is obviated. It should be said, 
however, that the danger from nitrous oxide gas is practically nil, 
whereas several cases are on record that died under chloroform. 

J. F. Bamhill claims that by the use of a Boeckmann curette (Fig. 221) 
as wide as can be introtluced through the isthmus of the ])harnyx the entire 
adenoid mass may be removed with one sweep of the instrument. This 
method precludes the accidental injury of the Eustachian pads, as often 
occurs with narrower instruments in the attempt to remove the lateral 
portions of the growth. 

Accortling to Moure the ej)ipharyngeal space varies greatly in shape, 
a fact which largely determines the completeness with which adenoids 
may be removed with the usual form of curette and forceps. If the 
epipharyngeal space is normal in shape (Fig. 212), the curette and 



ADENOIDS 



325 



forceps will completely remove the adenoids. If there is a recess in the 
vault (Fig. 213) these instruments will fail to remove all the tissue. If 
there is a recess in the posterior wall of the epipharynx (Figs. 214 and 
215), the forceps and curette of the usual type will fail to remove all the 




1, normal vault of the epipharynx from which adenoids may be removed with Boeckmann's 



curette; 2, posterior wall of the pharynx; 3, posterior end of vomer 
hard palate; 4, uvula; 5, hard palate; 6, sphenoid sinus. 



its normal relation to the 




An epipharynx witli an angular superior pouch, from which adenoids could be removed with 
a Hoeckmann curette, excepting, possibly, the upper angle of the pouch. This region might neces- 
sitate the use of a special curette. 1, 2, 3, 4, 5 and 6 refer to anatomical points (Fig. 212). 



tissue. These facts may account for many failures following adenoid 
operations. If there is a recess in the upper wall of the epipharynx, a 
specially designed curette (Fig. 216) should be used to complete the 
operation. If there is a recess in the posterior wall of the epipharynx, 



326 



THE PHARYNX AND FAUCES 



the IMeyer ring curette (Fig. 217) introduced through the nose, or the 
curette shown in P'ig. 218 should be used to complete the operation. 

Sequelae. — The Face.- — The development of the face is often materially 
modified by the presence of adenoids. The open mouth, the absence of the 




An epipharynx with a shallow posterior pouch from which the adenoids could be removed with 
Boeckmann curette, except in the posterior portion of the pouch. 1, a slight recess in the pos- 
terior wall of the vault of the epipharynx in which adenoids are inaccessible to the Boeckmann 
curette; 2, 3, 4, 6, and 6 refer to anatomical points. (After Moure.) 




An epipharynx with a deep pouch in the posterior wall, from which adenoids could not be 
removed with the Boeckmann curette. Such cases should be operated through the nose with 
Wilhelm Meyer's ring curette (Fig. 217), or with a specially curved curette (Fig. 218). 



nasolabial folds, the short upper lip, and the protruding and twisted 
central incisors of the upper jaw, the broad, flat, upper half of the nose, 
and the narrow, slit-like nasal openings, all conspire to give the so-called 
"adenoid face." The general expression is one of stupidity. The 



ADENOIDS 327 

degree of the facial disturbance varies greatly in different cases, usually 
in proportion to the degree of the nasal respiration, rather than the 
actual size of the adenoid growths. According to J. E. Schadle, the 
average capacity of the epipharynx is about 17 c.c, and its lateral is 
longer than its anteroposterior diameter. If the capacity of the epi- 
pharyngeal space is diminished, or its anteroposterior diameter is con- 
tracted, a small adenoid mass may produce a more pronounced nasal 
obstruction than a larger growth in a more roomy epipharynx. The 
facial expression is more modified in the former than in the latter in- 
stance. It should not be deduced from the foregoing statements that 
the indications for treatment are in proportion to degree of nasal obstruc- 



Special cuiette for reaching the recesses in the vault of the pharynx. 
Fig. 217 



Meyer's ring curette. 



V 






E.A.a&BDX s aa: CHic/iEo. 

Pynchon's pharyngeal curette. 

tion per se, as there are several other conditions resulting from small as 
well as larger adenoids that call for their removal as urgently as the 
complete nasal stenosis. 

The Interior of the Nose. — The interior of the nose is also modified in 
its development. J. S. Thompson called attention to this fact in an 
article wherein he states that the loss of the physiological stimulation 
incident to nasal respiration results in underdevelopment of the turbinals, 
and that deviated septa are common. Such individuals are more sub- 
ject to intranasal diseases, for obvious reasons. 

The Hard Palate. — Adenoid subjects usually have a "gothic" or arched 
palate, especially in its anterior portion. The arch is apparently higher 
than normal, though, as Newkirk has shown by numerous casts, the 
increased height is apparent rather than real. The illusion arises from 
the contraction of the lateral diameter of the upper jaw while tlie height 
of the arch remains the same, thus producing a marked dis])roj)ortion 
between its width and height. 



328 THE PIIARYXX AXD FAUCES 

The Teeth. — Tlie contraction of the lateral diameter of the arch some- 
times causes the central incisors to protrude and to be twisted upon their 
axes so as to cause their posterior surfaces to face. The teeth are often 
irregular, and require the services of a dentist to regulate them. 

Epipharyngeal Inflammation. — When adenoids are present the epi- 
])]iarvngeal mucous memhrane is almost always the seat of local inflamma- 
tions of both the acute and the chronic type. The low resistance of the 
adenoid tissue, the rarefied or abraded cylindrcial epithelium, the reten- 
tion of the secretions, and the insufficient ventilation of the epipharjngeal 
space all conspire to produce inflammatory processes. The inflamma- 
tion may be lacunar, either acute or chronic, or it may be a diffused 
catarrhal inflammation aft'ecting the mucosa covering the adenoids and 
the adjacent structures. 

The Auditory Apparatus. — Adenoids are a prolific source of tubal, 
middle ear, and mastoid inflammations. It is a common clinical experi- 
ence to see children with adenoids who complain of recurrent attacks 
of earache which is relieved by tympanic inflation. The Eustachian 
tubes are closed by catarrhal swelling, or "plugged" with thick, tena- 
cious mucus, and the air in the tympanic cavity becomes absorbed and 
rarefied. 

The drumhead is retracted and the mucous membrane lining the 
tympanic cavity is hyperemic. Tubal and middle-ear catarrh are thus 
established. 

Suppurative otitis media is also caused by adenoids. The infective 
material from the epipharynx enters the tubes and middle ear during 
the acts of coughing, sneezing, or other violent movements of the pharyn- 
geal and palatine muscles. Then, too, the ciliated columnar epithelium 
of the tubes may become rarefied or broken do\^m by the pressure of the 
opposed walls from the catarrhal swelling. The absence of the cilise 
permits the infected secretions to travel toward the middle ear, and 
infection thus becomes established in the tympanic cavity. 

Having gained a foothold in the tympanic cavity, it is but another 
step for the infection to invade the mastoid cells. The middle ear and 
mastoid inflammation is usually proportionate to the virulency of the 
microorganisms causing it. The labyrinth may also become involved 
in the infective inflammations of the middle ear, though such an occur- 
rence is rare. Deafness, in some degree, is always present in the fore- 
going ear complications of adenoids. 

The Mental Faculties. — The mental faculties are often much impaired 
in adenoid subjects. Among the mental states commonly present is 
that known as "aproscxla," or difficult attention. The child is listless 
and soon tires of his play, studies, or other tasks. He is "backward" in 
school in pronoimced cases, while in those in which there is little obstruc- 
tion his mental faculties are but little affected. 

The Respiratory System. — The anterior nasal openings are narrow and 
slit-like, while the turbinated bodies are underdeveloped. Catarrhal 
inflammation of the mucosa of the nose finds favorable conditions for 
its development. The lateral walls of the chest are contracted (Figs. 



ADENOIDS 



329 



219 and 220), thus throwing the ensiform cartilage into prominence. 
This characteristic deformity is known as "pigeon chest." The lungs 
are also undersized and respiration is shallow. The transfusion of gases 
through the walls of the air vesicles is impaired. Too little oxygen 
passes into the blood, while too little carbon dioxide is thrown off. The 
patient is both anemic and nervous, and is often irritable to a marked 
degree. 

The Bones. ^ — Frederick Coolidge called attention to the apparent rela- 
tionship existing between adenoids and the various forms of clubfoot. 
I have often confirmed the saying that "if you will show me a bow- 



FiG. 220 





Deformity of the chest due to adei 



3 type of chest deformity 
due to adenoids. 



legged man I will show you one that had adenoids in infancy." Adenoids 
affect the nutrition, partly through the anemia present and partly through 
the excess of carbon dioxide in the blood. These two conditions cause 
faulty metabolism and nutrition. The bones are deficient in lime salts, 
hence are soft and easily bent under the weight of the body. 

The Blood. — Adenoid patients are usually anemic. The red blood 
corj)Uscles are deficient in number and in hemoglobin. Carbon dioxide 
is present in excess. The nutrient qualities are diminished in quantity 
and quality. 



830 



rilE PIIARYXX AXD FAUCES 



Thomwaldt's Disease. — This condition is characterized by a suppura- 
ting canal in the reccssus medius or groove between the lateral halves 
of the adenoids. It is due to the inflammatory adhesions of the median 




Pharyngeal scissors. 

borders of the adenoid masses. That is, the recessus medius, a groove 
between the lateral halves of the adenoids, becomes converted into a 
canal. The lining membrane of the canal becomes infected and dis- 
charges purulent secretion. The symptoms are those of chronic pharyn- 
gitis attended by a cough. 

Fig. 222 




The operative treatment of Tliornwaldt's disease. a, the left blade of the pharyngeal scissors 
introduced into the suppurating sinus between the lateral halves of the adenoids; b, the right 
blade of the scissors at the border of the adenoid tissue. When the blades are closed the lateral 
half of the adenoids upon this side is severed. The scissors are then transferred to the other 
lateral half ol the adenoid tissue and closed. This completely severs the lower portion of the 
adenoid ti.ssue, and obliterates the suppurating sinus. The remaining upper jjortion of the 
adenoids, c erf, is then removed with the scissors or a curette. 

The canal may be seen by the use of a throat mirror, and a curved 
pro))e may be passed into it. 



THE LINGUAL TONSIL 331 

The author's method of treating it is to introduce one blade of the 
curved pharyngeal scissors (Fig. 221) into the canal and then cut off one 
lateral half with the scissors (Fig. 222) . This is a better way than to 
attempt to remove the adenoids in the usual manner, as the fibrous 
canal is so dense it is difficult to cut it. The posterior and remaining 
portion of the canal wall should be thoroughly curetted to remove the 
pyogenic membrane. 

THE LINGUAL TONSIL. 

The lingual tonsil is situated on the base of the tongue between the 
faucial tonsils and extends anteroposteriorly from the circumvallate 
papillae to the epiglottis. It is divided in the median line by the median 
glosso-epiglottic ligament. The tonsil consists of numerous rounded 
or circular crater-like elevations which are composed of lymphoid tissue, 
which at their circumference are surrounded by connective tissue. In 
the centre of each crater the mouth of the duct of a mucous gland opens. 
The crater or crypt is lined by stratified pavement epithelium. 

The lingual tonsil usually reaches its greatest development in young 
children, and, like the other tonsil structures, may begin to atrophy at the 
age of puberty. In the adult the number of masses is generally greatly 
reduced, though they may be greatly hypertrophied. 

Here, as in the other portions of the tonsillar ring surrounding the 
oropharynx, leukocytes are thrown out in great abundance. 

Acute Catarrhal Lingual Tonsillitis.— Acute catarrhal inflammation 
of the lingual tonsil is characterized by a moderate rise of temperature, 
painful deglutition, and a burning, pricking sensation in the throat. 
There may be some tenderness on pressure in the region of the great 
cornu of the hyoid bone. Upon inspection the pharynx and the pillars 
of the fauces may be slightly reddened, while the faucial tonsils may 
appear normal. The laryngeal mirror shows the lingual tonsil masses 
to be greatly reddened and swollen. 

Treatment. — The treatment consists in brushing the inflamed masses 
with a 20 to 50 per cent, solution of the nitrate of silver. 

Acute Lacunar Lingual Tonsillitis.— The symptoms of acute catar- 
rhal inflammation are present, and in addition the craters or crypts are 
lined with a whitish exudate and epithelial debris and microorganisms 
quite similar to the accumulations found in acute lacunar (faucial) 
tonsillitis. 

Treatment. — The treatment consists of the local application of a 20 to 
50 y)er cent, solution of the nitrate of silver. 

Acute Phlegmonous Lingual Tonsillitis.— This process is usually 
characterized by a purulent accinnulation beneath the lymph nodules at 
the base of the tongue, usually limited to one side. The temperature is 
elevated and the pain uj)on deglutition is severe. The patient complains 
of soreness and great tenderness upon pressure in the region of the great 
cornu of the hyoid bone upon the afl^ected side. Inspection with the 
throat mirror shows great swelling and redness at the base of the tongue 



332 THE PHARYNX AND FAUCES 

upon the affected side. Palpation with the finger may or may not eHcit 
fluctuation. 

riilegmonous inflannnation here, as in the faucial tonsil, may undergo 
resolution without the formation of an abscess. 

Treatment — Treatment consists of incisions into the swollen tissue. 

Hypertrophy of the Lingual Tonsil. — Hypertrophy of the lingual 
tonsil is rare in children and usually occurs between the twentieth and 
the fortieth years of life. It is more common in females. It is probably 
caused by repeated or continued infection of the lymph structures of 
the pliary)ix and fauces and epipharjnigeal tonsils. 

Symptoms — The symptoms are sometimes absent, though the sensation 
of a foreign body in the throat is usually complained of. There is a 
pricking sensation, as though a splinter had lodged in the i'auces, or 
the patient complains of the sensation of a lump, a hair, or other foreign 
body in the throat. Paresthesia of the pharynx presents the same 
symptoms (Ball), and hence neurosis of the phar^nix must be differ- 
entiated from this condition. So also must foreign bodies. According 
to Lennox Browne, troublesome fits of coughing are often present. 

During meals the symptoms disappear. Pain is rarely complained of 
except the disagreeable sensations already referred to. The use of the 
voice increases the symptoms, and often gives rise to the pricking sensa- 
tion and the cough. 

Upon examination w4th the throat mirror a few enlarged masses are 
seen upon the base of the tongue. Both sides are usually involved, though 
it may be limited to one. The masses may be so large as to push the 
epiglottis backward or even to overhang it. 

According to Ball, Seifert emphasizes the value of the use of the probe 
and of cocaine in the diagnosis between paresthesia of the pharynx 
and hypertrophy of the lingual tonsil. With the probe the patient is 
enabled to locate the sensitive areas giving rise to the symptoms, and 
the application of cocaine causes these areas upon probing to give forth 
no symptoms. 

Treatment. — The treatment is essentially surgical. Local applications 
of glycerin iodine, gr. xx to xxx to the ounce, afford relief by reducing 
the swelling and sensitiveness. Linear cauterization of the masses is 
an effective treatment, though the removal of the masses with stout, 
curved scissors has })roved to be the best treatment in my experience. 

Lingual Varix; Varicose Veins. — Lennox Browaie, in his treatise 
on the Throat and Nose, says that varix occurs in 10.6 per cent, of the 
cases coming to the Central London Throat, Nose, and Ear Hospital. 
As early as 1863, G. Lewin, of Berlin, reported on pharyngitis varicosa, 
with sensations of scraping, burning, and dryness of the pharynx. Since 
then many writers have reported similar cases, so that its existence 
as a rather common form of disease is well established. I have seen 
cases in my own practice w^hich presented the clinical picture described 
by Browne and others. It occurs more frequently in males, according to 
Browne (69 per cent.), though Swain and Seiss found it more frequently 
in females, while Seifert found it equally prevalent among males and 



THE LINGUAL TONSIL 333 

females. Excessive and improper use of the voice is an exciting cause. 
It is rare in childhood and most common between the twenty-fifth and 
forty-fifth years. Infectious injElammations of the pharynx and faucial 
tonsils and infection of the lymphoid tissue of the lingual tonsil prob- 
ably are the chief etiological factors. On account of the greater resist- 
ance to these influences possessed by the lingual tonsil, hypertrophy in 
this region does not occur as early in life as it does in the faucial and 
pharyngeal tonsils. Hence chronic infectious processes are often necessary 
to establish the hypertrophy of the lingual tonsil and varix of the veins. 
Browne believes that a constitutional or acquired debility of the vaso- 
motor system is the chief cause. Some cases are reported as occurring 
at the period of the menopause. Constipation and an obstructed portal 
circulation are etiological factors of some importance. 

Pathology. — I am indebted to Escat for the information that, according 
to Verneuil, "superficial varices only make their appearance when the 
deep varices have acquired a certain development." Escat also says: 
"Many kinds of neuralgia, otherwise inexplicable, are today attributed 
to circulatory troubles in the satellite veins of the nerves, and to a con- 
secutive neuritis." Quenu has thus explained certain neuralgias : " The 
trunk of the lingual nerve, the evident seat of a glossodynia, is in effect, 
according to Foucher, accompanied by a satellite vein, and even by two, 
according to Ziickerkandl." This anatomical fact is held by Escat to 
support his hypothesis, and that of Piotrawski, that all neuroses in this 
situation may be attributed to varices, superficial and deep. 

Symptoms. — As lingual varix is usually associated with hypertrophy 
of the lingual tonsil, the symptoms are about the same. Upon inspection, 
tortuous veins, bluish in color, are seen at the base of the tongue partially 
hidden by the hyper trophied tonsil. 

Treatment. — ^The treatment consists in applying the galvanocautery 
point to the enlarged veins, and the removal of the hypertrophied lym- 
phoid masses with the cautery point or with scissors. I have frequently 
resorted to these methods of treatment with satisfactory results. The 
after-treatment consists in gently massaging the wounds with a cotton- 
wound applicator dipped in a mixture of equal parts of glycerin, 
tr. ferri chloridi, and tr. iodini, at intervals of twenty-four hours. This 
prevents exuberant granulations and promotes healing with a smooth 
wound and a minimum of cicatricial contraction. 



CHAPTER XVIII. 

INFLAMMATORY DISEASES OF THE MESOPHARYNX AND FAUCES. 
SIMPLE ACUTE CATARRHAL PHARYNGITIS. 

This form of acute pharyngitis is usually accompanied by acute 
rhinitis, or "cold," though the pharynx may be chiefly affected. 

Etiology and Pathology. — The etiology and pathology is the same 
as given under acute rhinitis, though digestive disorders play a more 
prominent role in causing the disease. 

Symptoms. — The onset is characterized by malaise and a slight rise 
in temperature, as in acute rhinitis. The borders of the soft palate and 
the uvula are slightly red, while the adjacent mucous membrane is normal 
in appearance. As the disease progresses the uvula becomes slightly 
edematous and the secretions are increased. The uvula may become 
markedly edematous and painful, though this is not common. The 
tonsils are not usually involved, though they may become involved in 
severe cases. Pain is usually present, especially upon swallowing, and 
stiffness and aching of the neck muscles is complained of. Dysphagia or 
painful swallowing is a constant symptom. 

Diagnosis. — ^The erythema of secondary syphilis may be confounded 
with this disease. The differential points are (a) the darker or dusky 
color (in syphilis) of the mucous membrane; (6) the more marked involve- 
ment of the tonsils and soft palate, the diminished secretion; (c) the 
line of demarcation between the inflamed area and the hard palate; (d) 
the dusky symmetrical patches on the anterior pillars; (e) the opalescent 
appearance of the mucous membrane of the tonsils and the persistence 
of the disease, as contrasted with the evanescence of acute catarrhal 
pharyngitis. 

Treatment. — As the acute affection is somewhat dependent upon the 
presence of chronic rhinitis and sinuitis, these conditions should receive 
appropriate attention. The methods of treatment given for acute rhinitis 
are also of value, as the morbid process is almost identical. 

The anatomical peculiarities, however, render special modes of treat- 
ment necessary. 

Local treatment should vary according to the stage of the inflammation. 
Broadly speaking, astringents should be used in the first and third stages 
and sedatives in the second stage (Parker). They may be applied as 
gargles, sprays, paints, or lozenges. Gargles are suited to inflammations 
of the soft palate, uvula, and anterior pillars of the fauces. Sprays and 
paints are especially good methods of making local applications. Pre- 
liminary to all local treatment the alimentary tract should be evacuated. 



CHRONIC PHARYNGITIS 335 

From 5 to 10 grains of calomel, followed in six hours with a tablespoonful 
of castor oil, should be given. The following morning a tablespoonful 
of Epsom salt should be given to flush the bowels (Stucky). Having 
done this, the patient's condition is favorable for a speedy recovery under 
simple local treatments. 

The following mixture is recommended by Parker: 

I^. — Borax gr. xxiv 

Glycerin Vl\ xxiv 

Tincture of myrrh ITl xxiv 

Aquse des q. s. ad Sj 

Sig. — Use every hour as a gargle. 

If preferred, a gargle composed of 6 grains of alum, 15 grains of chlorate 
of potassium, to the ounce of water, may be used. 

The patient may be supplied with lozenges containing krameria or 
catechu, with instructions to dissolve one of them in his mouth every 
three hours. A cold compress should be worn across the front of the 
neck. 

After twelve hours red gum lozenges, which are very sedative, may 
be substituted for those containing krameria and catechu. A simple 
gargle containing 15 grains of the chlorate of potash to the ounce of water 
may also be used every three hours. 

The inhalation of steam charged with the compound tincture of 
benzoin, one tablespoonful to the pint of boiling water, should be used if 
the throat is painful. 

Pastils containing 3 grains of bismuth and -^-q grain of the acetate of 
morphia may also be dissolved in the mouth every three hours to relieve 
a painful throat. 

Should edema of the uvula occur, it should be scarified or amputated. 



CHRONIC PHARYNGITIS; GRANULAR PHARYNGITIS; LACUNAR 
PHARYNGITIS, OR CLERGYMAN'S SORE THROAT. 

This disease may or may not be characterized by pronounced sub- 
jective symptoms, as irritability and dryness of the throat. 

Etiology. — The chief etiological factors in the production of this 
disease are gouty and rheumatic diatheses, smoking and improper breath- 
ing in public speakers and singers, and the presence of morbid processes 
in the nose, accessory sinuses, and the epipharynx. Patients with 
a gouty or rheumatic taint complain of throat symptoms, whereas if they 
are free from gout and rheumatism they often make no such complaint. 
These conditions probably not only aggravate the pharyngitis, but to a 
certain extent influence its occurrence. Smoking to excess also aggra- 
vates and produces the inflammation. Clergymen, singers, auctioneers, 
and hucksters, who breathe through their mouths and abuse the vocal 
apparatus, are frequently afi^ected by chronic pharyngitis. Chronic 
rhinitis, and especially sinuitis, afi"ecting the posterior and ethmoidal 
and sphenoidal cells is very frequently the chief cause of the disease. 



336 THE PHARYXX AXD FAUCES 

The changed respiratory functions of the nose in these diseases sub- 
ject the pharpix and the lower respiratory tract in general to irritation. 
Of even greater importance is the discharge of heavy mucous or muco- 
])urulent secretions from the nose and accessory sinuses into the pharynx. 
The secretions are charged with pathogenic bacteria, and have undergone 
decomposition, whereby certain irritating chemical products are liber- 
ated, and as the secretions flow over the pharynx the pathogenic bacteria 
attack the weakened nuicous membrane and excite inflammatory reac- 
tions. The chemical irritation also adds to the reaction. 

I wish, therefore, to emphasize the importance of making a careful 
examination of the nose and accessory sinuses in all cases of chronic 
])iiaryngitis. 

Pathology. — The changes in the mucous membrane consist at first 
of an increased hyperemia and local leukocytosis, and later of the 
deposit of the least differentiated cells or connective-tissue cells. That 
is, hyperplasia of the mucous membrane occurs. The lymph tissue 
around the tubular glands of the phar}Tix are enlarged and are raised 
above the surface of the mucous membrane. Occasionally the tubular 
glands are filled with a whitish exudate or cheesy material. 

Symptoms. — Subjective symptoms are not always present, especially 
if the patient is free from the gouty or the rheumatic taint, or if they 
do not misuse the voice. In gouty and rheumatic patients who smoke 
to excess or breathe improperly the subjective symptoms are usually 
present. 

Subjective Symptoms. — In aggravated cases the voice becomes hoarse 
after moderate use, especially in public speakers, though the cords are 
neither red nor inflamed. According to Lennox Browne, the hoarseness 
is due to a spasm of the muscles of the phar>Tix and irritation of the 
superior lar}Tigeal nerve, which supplies the thyroarytenoideus, one of 
the tensor muscles of the cords. 

Smokers complain of a dr\Tiess or of the sense of a foreign body in 
the throat. They have a constant desire to hawk and expectorate. 

Cough may be present, though it is often absent. When present it 
is irritable and hacking in character. 

The secretions in the early stage of the disease are excessive, thick, 
and tenacious. At a later stage the glandular functions become im- 
])aired and the throat dry and glazed. 

The digestive tract is disordered, the breath foul, and constipation is 
the rule. 

Objective Symptoms. — Upon examination of the pharynx the mucous 
membrane appears redder than normal, at least in certain areas. In 
other areas it is pale and fibrous in appearance, especially in old chronic 
cases. Enlarged bloodvessels often extend across the posterior pharyn- 
geal wall. The secretion is often thick, heavy, and mucopin-ulent, 
though in the later stages it may be scanty and only form a film over the 
surface. In these cases the patient complains of dryness of the throat. 
The uvula is often relaxed and elongated (Fig. 226), and should be 
amputated. 



EDEMA OF THE UVULA 



337 



The lymph follicles of the posterior wall and of the lateral walls 
behind the posterior pillars of the fauces are enlarged from hyperplasia. 
This condition is often referred to as pharyngitis hyperplastica lateralis, 
a needless subdivision of chronic pharyngitis. The follicles are sparsely 
distributed on the posterior wall of the pharynx, but are closely grouped 
along the lateral walls. They appear as yellowish-red raised areas on 
the posterior wall and as nodular elongated masses behind the posterior 
faucial pillars. 

Prognosis. — In the early congestive stage simple astringent and 
demulcent local remedies combined with the regular use of a mild 
aperient mineral water will effect a cure. In the more advanced cases 
in which hyperplasia of the mucous mem- 
brane has occurred, and in which the Fig. 223 
lymph follicles are hypertrophied, improve- 
ment will only follow the destruction of 
the tubular glands around which the lymph 
masses are located. 

Treatment. — In mild cases and during 
the early stage of the disease, or before 
it has advanced to marked hyperplastic 
and hypertrophic changes, the remedies 
given under acute catarrhal pharyngitis 
may be used with some success. 

Aperient salines should be given daily 
for a long period to eliminate the gouty 
and rheumatic toxic material and to free 
the stomach and intestines of putrefactive 
material. 

In the well-advanced cases the lymphatic 
nodules, whether discrete or massed, as they 
may be on the lateral walls behind the pos- 
terior pillars of the fauces (pharyngitis hyperplastica lateralis), should be 
punctured with a cherry-red cautery electrode (Fig. 223). The mucous 
membrane should be brushed once or twice with a 10 per cent, solu- 
tion of cocaine, and from four to five hyperplastic follicles biu'ued out 
with the electrode. Follow with a spray of Seller's solution, to soothe 
the burned areas. At the end of the fifth or sixth day four or five 
more follicles may be treated in a similar manner, and so on until they 
are all destroyed. This course of treatment is often very beneficial, 
though it may fail if the gouty or rheumatic diatheses are not also 
corrected. When the uvula is elongated it should be amputated. 




Showing tlie cautery point applied 
to pharyngeal follicular glands in the 
treatment of follicular pharyngitis. 
From four to five follicles may be 
thus treated at a sitting under 
cocaine anestliesia. 



EDEMA OF THE UVULA. 



Acute inflammation of the faucial structures, especially of the periton- 
sillar tissue, is frequently attended by edema of the uvula. 

The treatment generally recommended is scarification or multiple 
22 



338 T^W: PHARYNX AXD FAUCES 

punctures, to allow the excess of serum to escape. A more rational 
procedure would be to promote a freer flow of the blood through the 
tissues, and thus remove the obstruction to the blood current through 
the veins. The application of the rays of light and heat from a 500 
candle-power electric lamp (Fig. 19) to the neck at the angle of the 
lower jaw acts admirably in this way. The lamp should be suspended 



.u^^^l^l 




Edema of the uvula. 



at a distance of eighteen inches from the patient and slowly passed 
back and forth over the neck for from fifteen to thirty minutes, three 
times daily. The patient's neck should then be sponged with iced water 
to prolong the hyperemia. 

Astringent lozenges containing krameria and alum may be used with 
comfort to the patient. 



ELONGATED UVULA. 

An elongated uvula is not a disease per se, but is a symptom of a 
chronic pharyngitis, especially epipharyngitis. The relaxed pendulous 
condition of the uvula is due to the irritation resulting from the epi- 
pharyngeal discharge and to the changed nutrition attending the epi- 
pharyngeal infection and inflammation. The uvula may be slender and 
pendulous, or it may be enlarged (hypertrophied) and pendulous. An 
elongated and elastic uvula is sometimes observed as an idiopathic con- 
dition, as shown in the author's case (Figs. 225 and 226). 

Symptoms. — In rol)Ust subjects it causes but slight or no symptoms. 
In sensitive patients it often causes a reflex cough when it touches the 
epiglottis or the base of the tongue. The cough may be spasmodic, and 
is usually dry. Nausea and vomiting, especially early in the morning, 
are sometimes com])lained of. Patients have applied to me for the relief 
of the persistent hacking cough, fearing tuberculosis had set in. An 
examination of the lungs failed to reveal disease in that region, whereas 



ELONGATED UVULA 



339 



an examination of the throat showed the presence of a long pendulous 
uvula. The amputation of the lower relaxed portion of the uvula imme- 
diately stopped all symptoms. 




Fig. 226 


,(^^^\ 


M, 



Fig. 225. — Author's case of elastic uvula. (See Fig. 226.) Note the spiral arrangement of the 
mucous membrane of the uvula when the muscle of the uvula is contracted. 

Fig. 226. — Author's case of elastic uvula, evincing no tendency to elongation when at rest. 
(See Fig 225.) 

Fig. 227 




The amputation of the elongated tii> (jf the uvula just below the lower extremity of the innscle. 
The sci.ssor.s are so applied that the posterior surface of the uvula will be the wound surface. 
This prevents irritation in swallowing food and in breathing through the mouth. 



Treatment. — In simple cases astringent remedies, as lozenges con- 
taining krameria, afford relief. 1'hc uvula may also be painted with 
astringent solutions of alum, tannic acid, or with adrenalin. In the 



.340 



THE I'llMiYXX AM) FAUCES 



more pronounced ca.se:^ amputation is indicated. In 

pharynx and the 

the diseased conditions treated. 



cases the epi- 



niesopharynx (oropharynx) should be examined and 



Fig. 228 






Three views of the amputated uvula. 
Fig. 229 

i 



anterior view; b. 



lew; c, posterior view 






Casselberry's operation fn 
uvula. 



elongated 



Surgical Treatment. — (a) The uvula 
should he painted with a 10 per cent, 
solution of cocaine. 

(6) The tip of the uvula is then seized 
with forceps and drawn directly for- 
w^ard. 

(c) While in this position it should 
be operated with heavy blunt scissors, 
as shown in Fig. 227. 

By cutting the uvula from in front 
while drawn anteriorly, the bevelled cut 
surface of the stump faces posteriorly. 
This is a point of practical importance, 
as in swallowing solid food the raw 
surface is not irritated by it (Fig. 22S). 

Casselberry's Operation. — Dr. Wm. E. 
Casselberry recommends the following 
technique in the amputation of the 
uvula : 

(a) Secure anesthesia by painting the 
uvula with a 10 per cent, solution of 
cocaine. 

(b) Seize the tip of the uvula with 
forceps and draw it directly forward. 

(c) While in this position an upward 
and medianward cut is made with scis- 
sors to the central axis of the uvula. A 
similar cut is made on the opposite side, 
thus removing a wedge-shaped piece of 
the uvula, as shown in Fig. 229 



RETROPHARYNGEAL ABSCESS 341 

(d) The anterior and posterior cut edges of the wound are then 
secured with two or three black silk sutures, black thread being used, 
because it is easier to locate at the time of its removal. 

(e) The sutures should be removed at the end of three days. 

The advantages claimed for this method of operating are that the cut 
surfaces are sealed and not liable to irritation from the ingested food, and 
to infection from ingested and inhaled pathogenic bacteria. 

Hemorrhage has been reported after uvulotomy. This may be avoided 
by limiting the amputation to the portion of the uvula below its muscular 
fibers; that is, only the thin relaxed portion should be removed, as the 
bloodvessels of the uvula do not extend beyond the muscular fibers. 



RETROPHARYNGEAL ABSCESS. 

An abscess on the posterior wall of the pharynx may be acute or 
chronic, usually chronic. It may be situated in the mesopharynx, the 
hypopharynx, or the epipharynx. 

Etiology. — There is an infection beneath the mucous membrane. 
The morbid germs gain entrance through the lymph vessels and have the 
atrum of invasion in one of the neighboring tissues which is diseased. 
Tonsillitis, a postoperative tonsillar wound, a tuberculous tonsil, tuber- 
culous cervical glands, caries of the vertebra and syphihs of the throat 
may be the immediate predisposing causes. The author observed one 
case following the complete excision of the tonsil in an adult. Most 
of the chronic cases occur in tuberculous and strumous children. Post- 
phar}Tigeal abscess is often associated with tuberculous glands of the 
neck. The glandular involvement is probably secondary to the pharyn- 
geal abscess, or both may be secondary to a tuberculous affection of some 
other structure. 

Symptoms. — The patient complains of painful deglutition, and, if the 
swelling is in the hypopharynx, of dyspnea, which may threaten life 
or even cause death. Cough is constantly present. The voice is similar 
to that present in quinsy. In acute abscess the temperature may be 
elevated from 1° to 2°, whereas in chronic abscess it is little altered. 

Diagnosis. — The abscess should be differentiated from aneurysm, 
malformation of the vertebrae, and inflammatory swelling of the mucous 
membrane. 

Aneurysm of an artery in this region has been mistakenly diagnosticated 
as retrophar}Tigeal abscess, with fatal results following incision. The 
pulsation and bruit present in aneurysm should be sought for in all cases 
of suspected abscesses of the phar}Tix. The pulsation may be noted 
with the eye or finger, while the bruit may be distinguished with the 
stethoscope introduced through the mouth. 

Malformation of the posterior wall of the pharynx, causing bulging 
of one side, is occasionally found. The hard, firm character of the mass 
readily distinguishes it from the soft baggy mass in abscess formation. 

Acute infectious inflammations of the pharyngeal mucous menil)raiie 



342 



THE PJIARYXX AXD FAUCES 



sometimes simulates retropharvniijeal abscess. The difference in the 
resistance upon <Htj;ital examination will determine which of the pro- 
cesses is present. 

Prognosis. — The dan<i;er in v(>rv young subjects is chiefly due to 
sulVocation, and to strangulation ui)on the spontaneous rupture of the 
abscess. In older patients this danger is not so pronounced, as their 
reflexes enable them to ward off" or anticipate these dangers. Under 
treatment the prognosis is nearly always good except when the disease 
is due to tuberculous caries of the vertebrse. 




Tho oral oiipration for retropharyngeal abscess. The finger is used as a guide to tlie fluctuating 
area anil as a tongue depressor, while a short-bladed scalpel is used to open the abscess. 

Treatment. — The main indication for treatment is the immediate 
evacuation of the pus. This may be accomplished by (a) the internal 
or (&) the external route. The internal operation should always be 
tried flrst, and followed by the injection of iodoform glycerin emulsion 
(Esmarch and Kowalzig). Should simple puncture and evacuation, 
followed by the injection of the iodoform emulsion, fail the external 
operation should be performed. 

Technique. — Internal Operation. — (a) Place the patient upon a table 
with his head lowered, to prevent the larynx being bathed in pus. In 
children this precaution is especially in-gent, as their reflexes are not 
sufficiently trained to prevent suction of the infected secretions into the 
trachea and lungs, where it might cause aspiration ])neumonia. 

(/;) Introduce the left index finger into the mouth and place the tip 
against the soft flucdiating tiimoi\ 



RETROPHARYNGEAL ABSCESS 343 

(c) Introduce a short-bladed scalpel, or a longer one, the proximal end 
of which is wrapped with a strip of adhesive plaster or cotton into the 
mouth, using the introduced finger as a guide (Fig. 230). 

(d) Incise the abscess wall by the side of the finger. The pus then 
flows through the incision into the pharyngeal cavity, from which it may 
be removed with moist gauze sponges grasped by artery forceps, or it 
may be expectorated by the patient. 

(e) After all the pus has been thus removed, irrigate the cavity with 
warm boric acid solution and inject the iodoform glycerin emulsion 
into the wound. The injections may be repeated every day or two, and 
if steady improvement follows, a cure may be expected. If, however, 
improvement does not follow, the external operation should be per- 
formed. 



f 





The external operation for retropharyngeal abscess. The fascia enclosing the abscess is 
punctured and opened with artery forceps. 

External Operation. — Generally speaking, the external operation 
consists in making an excision either anterior or posterior to the sterno- 
mastoid muscle, and extending it inward by blunt dissection to the 
anterior wall of the vertebral column, where the abscess cavity is located. 

If only the retropharyngeal abscess is to be included in the operation, 
the incision should be made posterior to the stern omastoid muscle; if, 
however, there are diseased cervical glands to be removed at the same 
time, the incision should l)e made anterior to the muscle (Fig. 231). 

The following steps in the operation should be observed: 

(rt) The field of operation should be shaved and scrubbed. 

{!)) (jeneral anesthesia. 

(c) An incision two or three inches long should be made through the 
skin over either the anterior or the posterior border of the sternomastoid 
muscle on a plane with the retrophar^mgeal abscess. The dissection 
should be continued until the deep cervical fascia is o])en(>d and (he 
border of the sternomastoid muscle is brought to view. 



344 THE PHARVyX AXD FAUCES 

{(l) The sternoinastoid muscle is then separated by Ijhint dissection 
from the adjacent tissues, and is drawn forward with a retractor to 
expose the oj)erative field. 

{e) Still usino; blunt dissection, the carotid sheath with its vessels and 
nerves is separated from the vertebra and carefully drawTi forward. 

( /') The dissection is carried in front of the vertebra to the abscess 
wall. 

((/) The abscess wall is punctured with closed artery forceps; the 
forceps is then introduced into the cavity, the blades spread apart, and 
withdrawn from the cavity (Fig. 231). The abscess is thus freely 
ojKMied and evacuated. 

(/t) Digital examination of the cavity should be made for necrosed 
bone, and to note the condition of the soft tissues and abscess contents. 
If the secretions are thick and caseous, they may be removed by gentle 
curettage. 

(i) Irrigation with warm boric acid or the glycerin-iodoform solution 
completes the evacuation of the contents of the abscess. 

(J) Introduce a spiral tube deep into the wound for drainage purposes. 
The tube may be withdrawni a little each day after the discharge has 
ceased, and abandoned altogether at the end of ten days or two weeks, 
after which the external wound closes by granulation. 

If cervical glands are to be removed, or if the abscess points anteriorly 
to the stemomastoid muscle, the incision should be made anterior to the 
muscle. The group of glands involved should be removed en masse, as 
to leave some of them almost surely means a secondary operation. 



MALFORMATIONS OF THE PHARYNX; STENOSIS OF THE PHARYNX. 

Malformations of the pharynx may be either (1) congenital or (2) 
acquired. 

Those of congenital origin may be in the form of an imperforate 
phar^iix, from a failure in the embryological development of the anterior 
end of the foregut, and the invagination of the ectoderm, which forms 
the cavity of the mouth. The embryological structures in this region are 
very complex, and it is a wonder congenital malformations are not more 
frefjuent. Congenital malformation is usually in the form of a con- 
striction or pouch, or of a complete closure. 

Acquired malformations are due to inflammatory and degenerative 
changes in the walls of the pharynx. Syphilis is the most common 
cause. There is more or less destruction of the uvula and soft palate 
in the tertiary stage, followed by cicatricial contraction and adhesion to 
adjacent parts. The soft palate in these cases is usually adherent to 
the posterior wall of the pharynx, and may cause almost complete 
separation of the mesopharMix from the epi})har}mx. In Fig. 202 there 
is only a small opening the size of a lead pencil communicating with the 
epipharynx. The scars in syphilis are stellate in their arrangement, 
i.e., they radiate from the site of the original ulceration. The inges- 



MALFORMATIONS OF THE PHARYNX 345 

tion of scalding fluid and caustic drugs may cause scar tissue and 
cicatricial contraction. 

Treatment.- — The treatment of syphilitic scar tissue and adhesions is 
attended by failure in the majority of cases. The scar tissue may be 
removed and the adhesions broken down, though they speedily reform and 
re-adhere. Obturators have been used in the isthmus between the meso- 
pharynx and epipharynx, to keep the channel open and to prevent 
adhesions, with occasional success. The tendency for syphilitic scar 
tissue to reform in spite of all obstacles is the chief hindrance to the 
successful treatment of these cases. 



CHAPTER XIX. 

THE FUXCTIOXAL NEUROSES OF THE PHARYNX. 

Neuroses of Sensation. — The train of symptoms in pharyngeal 
neuroses of sensation is about the same as in the larynx, many of them 
being due to reciprocal lesions. (See Neuroses of the Larynx.) 

Anesthesia of the pharynx is not of any great clinical significance, 
excepting, perhaps, when it accompanies progressive bulbar disease. 
Insane patients are apt to have it, even though no form of paralysis is 
present in the phar\nix or elsewhere in the body. In cases of marked 
anesthesia involving the whole pharynx, the soft palate and lar\iix are 
usually likewise anesthetic. Diphtheria often causes it, and it sometimes 
accompanies the other exanthematous fevers. It may even be present 
in local inflammations of the pharyngeal mucosa. 

(For treatment, see Anesthesia of the Lar>aix). 

Hyperesthesia of the pharynx is the most frequent of the phar^mgeal 
neuroses. It often occurs in those who are otherwise healthy. These 
cases do not tolerate the lar\aigoscopic mirror in throat examinations. 
They also resist the introduction of the Eustachian catheter. The most 
sensitive areas in the phar^mx are the arch of the soft palate and the 
vault of the epipharynx. 

Hypersensitiveness accompanies both acute and chronic inflammation 
of the pharynx. It is also a frequent manifestation of hysteria. It is 
more common in men, and especially fat men. Habitual smokers and 
drinkers are subject to it. It is but rarely a symptom of central brain 
disease. The hypersensitive areas sometimes appear on the tongue. 

Paresthesia occurs about as frequently as anesthesia, and less fre- 
cjuently than hyperesthesia, and often baffles the skill of examiners and 
operators. Tonsillar disease is often the cause of it, hence these organs 
should l)e thoroughly examined for diseased conditions. The passage 
of a bolus of food or foreign body may cause an abrasion, which may be 
followed by the sense of a foreign body in the throat. The menopause 
is fre(|uently attended by perverted sensations in the pharynx I have 
had ])atients at this period complain of the sensation of a rope or hairs 
in the throat. Hyperplasia of the lingual tonsil seems in some cases to 
cause it. The same is true of elongation of the uvula, though the 
elongated uvula is usually a sign of epipharvngitis, and the paresthesia 
may be due to the "drop])ing" \'ron\ the epipharyngeal region. Granu- 
lar pharyngitis, especially when it involves the lateral walls (pharyngitis 
hypertropliica lateralis), gives rise to an irritation between the pos- 
terior pillars and the pharyngeal wall, which is sometimes accompanied 
by paresthesia. It is occasionally associated with globus hystericus. 

The j)erverted sensations couij)lained of are cold, heat, a foreign body. 



THE FUNCTIONAL NEUROSES OF THE PHARYNX 347 

itching, tickling, and the dislocation of the essential parts of the fauces 
and pharynx. Patients sometimes complain of swallowing the soft 
palate, etc. Most of the female cases seen by me have suffered from 
melancholia during the menopause, and have had a suicidal tendency. 
One patient committed suicide by drowning some months after she passed 
from under my observation. The paresthesia may be so marked as to 
cause a distressing cough and laryngeal or esophageal spasm. 

Neuralgia of the pharynx is difficult to differentiate from muscular 
rheumatism or neuralgia. Neuralgia is painful without pressure, while 
rheumatism is painful with and without pressure. Anemia and chlorosis 
are often the cause of neuralgia, whereas rheumatism is more often 
associated with plethora. Enlarged single pharyngeal follicles may 
become so painful as to simulate neuralgia. Localized pressure upon 
the follicles should cause pain and thus clear the diagnosis. 

The treatment of neuralgia should be addressed to the cause when it 
can be determined, as well as to the relief of the pain. Iron, stryclmine, 
arsenic, bitter tonics, and the regulation of the bowels should be the 
basis of the treatment in those cases in which anemia is the cause. 
In chlorosis enemata should be given to unload and cleanse the 
rectum and lower bowel, to stop the absorption of putrefactive 
material and bacteria into the circulatory system. Exercise in the open 
air and sunshine is of the greatest value in these cases. Patients should 
be encouraged to play golf or other outdoor sport, or to work in the 
flower or vegetable garden, or in the poultry yard. The outdoor 
exercise should have a constant and alluring motive, or it vdll soon be 
abandoned. 

Neuroses of Motion. — Neuroses of motion of the pharyngeal muscles 
may, like those of the larynx, be divided into two general classes (Browne) : 

1. Akinesis, or paralysis, which may be unilateral or bilateral. The 
akinesis, or paralysis, may be still further subdivided into: (a) Paralysis 
due to bulbar disease (central paralysis). (6) Paralysis due to diph- 
theria (peripheral paralysis) . (c) Paralysis due to or complicating faucial 
paralysis (central or peripheral paralysis) . (d) Paralysis of the pharyn- 
geal constrictors. 

2. Ilyperkinesis, or spasm. 

Paralysis Due to Bulbar Disease; Central Paralysis. — The following 
central lesions may give rise to pharjaigeal paralysis : acute and chronic 
bulbar myelitis, hemorrhage, tumors, embolism, and basilar meningitis. 

Acute Bulbar Paralysis; Central Paralysis. — Symptoms. — In acute 
l)ulbar myelitis the symptoms develop rapidly, and the fatal end result 
is likewise rapid. The symptoms are as follows: 

(a) Suddenness of attack. 

(b) Severe headache. 

(c) Dysphagia. 

(d) Res])iratory embarrassment. 

(e) Difficulty in articulation. 
(/) (liddiness. 

{(j) I 'Usteady gait. 



348 THE PHARYXX AXD FAUCES 

Prognosis. — The prognosis is extremely grave. 

Treatment. — ^Vllile these cases are ahnost necessarily hopeless, they 
should be treated, for "while there is life there is hope." Bloodletting 
by cupping or leeches should be early and freely employed, to relieve the 
inflammatory ])rocess at the base of the brain. Ice should be applied to 
the pharynx and to the nape of the neck. The blood tension should be 
lowered by the administration of cathartics and such other remedies as 
are employed for spinal myelitis. 

Chronic Bulbar Paralysis; Central Paralysis. — Undue exposure to cold, 
prolonged violent excitement, extreme fatigue, and lack of nutrition are 
etiological factors. Heredity seems also to largely influence its occurrence. 
It is more common in males, and is rarely observed before the age of 
thirty-five. In rare cases it may be due to an injury or to sunstroke. 
Syphilis and tuberculosis should also be included as causative agents. 

Symptoms. — Pharyngeal paralysis may be the first symptom of pro- 
gressive bulbar disease, though the tongue is usually the first organ 
affected. A typical case first involves the tongue, and is then followed 
by paralysis of the lips, the pharpigeal and lar;)Tigeal muscles. This 
order of involvement is almost always present. The paralysis, at first 
slight, gradually increases in severity. 

Diagnosis. — In the beginning the disease may be mistaken for bilateral 
facial paralysis, though the history of a sudden onset, followed by progres- 
sive chronic paralysis of the tongue, phar^qix, and larynx, together with 
the lips, should render the diagnosis of bulbar paralysis almost certain. 
In bilateral facial paralysis the tongue, pharynx, and lar^Tix are not 
atfected. In rare cases the tongue and fauces are not involved. 

Prognosis. — The prognosis is usually fatal, though there may be re- 
missions before death occurs. Patients often succumb to inanition or 
pneumonia. 

Treatment. — Galvanism has been used to combat nerve degeneration 
and faradism to maintain the muscular vigor, with but little success. 
Strychnine is of value as a nerve tonic. In syphilitic cases the iodides are 
indicated. 

Diphtheritic Paralysis; Peripheral Paralysis. — Paralysis of the pharyngeal 
muscles is often an early sequel of diphtheria and of pseudomembranous 
sore throat. The muscle fibers undergo more or less degeneration from 
the presence of the bacterial toxins, and there is a mechanical hindrance 
from the cellular infiltration of the tissues. In addition there is a degener- 
ation of the ])eripheral nerve fibers from the same causes. 

Symptoms. — The voice undergoes great changes on account of the 
paralysis of the pharyngeal muscles, as they are utilized in articulation 
and voice placement. The voice has the so-called "nasal quality," 
closely resembling that present in cleavage of the hard and soft palate. 
The velum and uvula are relaxed and can only be raised by forced in- 
spiration. One side is usually more affected than the other, or it may 
be bilateral. The ])aralysis appears on or about the fifteenth day after 
convalescence, at which time ocular sym})toms may also develoj). 



THE FUNCTIONAL NEUROSES OF THE PHARYNX 349 

Treatment. — The prophylactic treatment consists in the administra- 
tion of antitoxin during the diphtheria. After the paralysis has developed, 
galvanism, faradism, and rectal feeding should be adhered to in order 
to maintain muscular and nervous tone while the degenerated nerve 
fibers are being restored. Thick soups, grape juice, etc., may be given 
per rectum. 

Paralysis of the Pharynx Complicating Facial Paralysis. — According to 
Ziemssen and Bouche, when the lesion is above the geniculate ganglion 
the pharynx is often associated with facial paralysis. The uvula does 
not move upon phonation and is deflected to one side. The symptoms 
are the same as those in diphtheritic paralysis, and include such structures 
as are supplied by the seventh nerve. 

Paralysis of the constrictor muscles of the pharynx is always accom- 
panied by paralysis of the esophagus. The dysphagia is, therefore, 
exceedingly well marked, and is often the only distinctive symptom. 

Hyperkinesis, or Spasm of the Pharynx. — Etiology. — Spasm of the pharyn- 
geal muscles of the pharynx is a rare affection. It may occur from 
insignificant causes, as uvulitis, foreign bodies, globus hystericus, 
enlarged pharyngeal follicles, neuralgia, and chronic and acute inflamma- 
tions, or it may be an early symptom of a serious central lesion. 

The more dangerous form of spasm of the pharynx is encountered 
in hydrophobia, edema of the glottis, brain tumors, paralysis agitans, 
and other nervous conditions. 

Symptoms. — Chronic spasm of the pharynx involving the soft palate 
and uvula may be the chief symptom. The levator palati is the muscle 
affected. The spasm of this muscle draws the soft palate upward a 
number of times in rapid succession, after which it relaxes. During 
the spasm there is a clicking noise as the palate leaves the pharyngeal 
wall. The click is audible to those near by. Inspection shows the 
adhesion which upon being overcome causes the noise. 

Prognosis. — ^The prognosis is fair in those cases due to simple causes, 
provided appropriate treatment is instituted. If due to a serious central 
lesion, hydrophobia, edema of the glottis, brain tumor, or paralysis 
agitans it is grave. 

Treatment. — If the spasms are due to a foreign body, it should be 
removed. If due to local inflammations, appropriate remedies, else- 
where described, should be used. When due to saprophytic absorption 
from the rectum the lower bowel should be flushed by enemata, outdoor 
exercise advised, and a nutritious but unstimulating diet followed. When 
due to hydrophobia it sliould be treated rather than the spasms of the 
j)liarynx which are incidental to the disease. Stimulants of any sort 
should be avoided in all cases. 



CHAPTER XX. 

NEOPLASMS OF THE PHARYNX. 
BENIGN NEOPLASMS. 

(a) Papillomata. — Papillomata of the walls of the phar\nix are rather 
rare, while thev are eoininon in the faucial region. Their favorite sites 
are upon the uvula, free l)orders of the pillars of the fauces, and the 
tonsils. The histological differences between the mucous membrane of 
the posterior wall of the pharynx and the mucosa of the uvula, pillars, 
and tonsils account for the sites elected. The posterior wall of the 
pharynx is covered by squamous epithelium, whereas the other struc- 
tures are covered by columnar, and in many places by columnar ciliated 
epithelium. In spite of the varying structural differences, papillomata 
appear in all parts of the pharynx and fauces, though more frequently 
in the fauces. 

They may be single or multiple, sessile or pedunculated. Behind 
the fauces, or in the pharpix proper, they are rarely pedunculated, and 
are chiefly limited to the raggetl excrescences following syphilitic and 
lupus inflammations. Papillomata are composed of elevations of 
epithelial cells which contain a connective-tissue core more or less richly 
supplied with bloodvessels. The epithelial elevations grow outward, 
while in epitheliomata they grow inward. The elevations vary in 
size from a pinhead to tumors of considerable size. They often contain 
"pearls" or "nests," which may be mistaken for the nests or pearls of 
epitheliomata. The cells in papillomata are uniform, whereas in epithe- 
liomata they are multiform. Papillomata are liable to become converted 
into epitheliomata of the malignant type, hence they should always be 
viewed with suspicion. They may be in the transitional stage when 
observed, though most of them are true papillomata with an outward 
growth of the epithelial elevations. 

Primary papillomata are usually surroimded by an inflammatory area. 
Secondary j)apillomata are the result of a preexisting inflammation, 
as in syphilis (Fig. 232). 

The presence of a papillomatous growth in the fauces or pharynx 
often excites a cough reflex, with a sense of fulness and tickling in the 
throat. 

Treatment. — The treatment of papillomata is usually so simple that 
a detailed description of the procedures need not be given. The tumor 
should be removed to its base with a knife, snare, cutting forceps, or 
cautery. The base of the growth should be removed or cauterized with 
solid silver or the galvanocautery. If this is not done they are apt to 
recur. 




BENIGN NEOPLASMS 351 

(b) Teratomata. — Lennox Browne says, " The connection between 
teratomata and cystomata is so intimate and their origin so obscure 
that it is expedient to describe them together." I shall not do this, 
but will attempt to characterize them as distinct pathological entities. 

Teratomata are usually congenital and consist of tissue growths 
springing from two or three embryological germinal layers. They appear, 
therefore, most frequently in those regions where the various germinal 
layers are in close apposition (Browne). The pharynx, resulting prac- 
tically from the junction of the neural and the dermal epiblasts with the 
hypoblasts of the foregut, is, therefore, a suitable location for the growth 
of teratomata. Bland-Sutton called attention to this fact in 1886. 

The majority appear in the epipharynx, though quite a few recorded 
cases were in the meso- and hypopharynx. They were sometimes called 
"hairy pharyngeal polypi," as they are 
usually pedunculated cysts filled with hair Fig. 232 

and other histological structures. 

Conitzen reported 11 "hairy polypi," or 
teratomata, which were cystic and contained 
hair, cartilage, skin structure, and bone. 
The cysts are usually pedunculated, and 
may be attached to any part of the 
phar}'Tix. 

Treatment. — The treatment consists in ''^■'^^ '^ 

the removal of the growth with the snare, , .^""'^^ l^Z""^ ^""jf^^^^ *°".^''- 

'^ . . ' litis and syphilitic papilloma arising 

knife, or cautery. Cauterizmg the base from the left supratonsiUar fossa. 
seems to prevent recurrences. 

(c) Cystomata. — They usually occur after the twentieth year of life, 
more often in middle and advanced age. They are usually retention 
cysts or mucoceles, due to the closure of the mouths of the pharyngeal 
follicles, either by inflammatory contraction, epithelial plugs, or by the 
flaccid folds of membrane in advanced life. The cysts contain a glairy 
fluid, though in some cases it is inspissated and much thickened. They 
are usually superficially located, though Raugi speaks of a submucous 
cyst occurring in the submucous tissue which was difficult to see, and 
which he thinks must occur much more often than is generally believed. 

Cysts are usually sessile, and often give rise to the symptoms described 
under reflex neuroses, as asthma, migraine, etc. 

Treatment. — The treatment consists in the enucleation of the cyst 
ineml)rane, though thorough cauterization of the lining of the sac is 
usually followed by the obliteration of the tumor. 

(d) Lymphomata or Lymphadenomata. — This variety of benign 
tumor is the most frequent growth in the pharynx. This is to be 
expected on account of the widely disseminated tonsillar tissue and 
the numerous lymphoidal vestiges. The matrix of the tumor is con- 
nective tissue, in the meshes of which are aggregated the lymphoid 
cells. The cell groups are often crowded together and vary greatly in 
size. They have a strong tendency to multiplicity, just as in 
lymphoidal tumors elsewhere. They may be attended by or even 



352 THE PHARYNX AND FAUCES 

follow mediastinal complications of a like nature (Villar). A single 
tumor, especially when pedunculated, at times offers some diagnostic 
difficulties. But when we take into consideration that the adjacent 
lymphatic glands in the neck are enlarged and soft, the tumor in the 
pharjnix, though pedunculated, should be suspected to be lymphoma tons. 

(e) Myxomata. — Tvlyxomata of the phar}Tix is exceedingly rare. 
Browne in his whole experience never saw a case. Closely allied to them, 
however, are the so-called mucoceles due to dilatations of the mucous 
glands. The mucoceles are important as they are readily recognized 
and are easily eradicated by excision or the actual cautery. 

(J) Fibromata. — After lipomata, fibromata are next in order of fre- 
quency. The structural arrangement is often so like that of sarcomata 
it is difficult to differentiate them. The clinical history is, therefore, 
the guide in diagnosis. In very rare instances a myxomatous tumor 
may take on the tendencies and aspects of a fibroma, just as primary 
fibromata may become mucoid in character. Fibromata are rare in 
advanced age, but are quite common in young and middle adult life. 
This seems to be true of nearly all neoplasms springing from the mesoblast. 

Fibromata may be either sessile or pedunculated, more often the 
latter. They are composed of densely packed spindle cells, with an 
undeveloped matrix of connective tissue. They are encapsulated, and 
do not often attain a large size. Bruns reports a case in which the entire 
fauces w^as filled by a fibroma. They are usually single and of slow 
growth. They have their origin in the fibrous tissue and the periosteum 
of any part of the pharynx. The covering of the basillar process of the 
occipital bone and body of the sphenoid are favorite sites. As the ptery- 
goid plate of the sphenoid and the perpendicular plate of the palate 
bone, the posterior ends of the upper turbinated bodies, and the posterior 
portion of the vomer are all covered with fibrous tissue and perios- 
teum fibromata usually arise from this region. Large fibromata are 
frequently attended by inflammatory processes, hence adhesions to the 
adjacent structures is common. 

Etiology. — They are rare in females. Age is a decided factor in their 
occurrence, adolescence being the favorite period. As age advances 
there is a tendency for the growths to recede or undergo^spontaneous 
cure. In this respect they resemble adenoids and other lymphatic 
enlargements. 

Symptoms. — The early symptoms are those of epipharyngeal catarrh, 
with more or less hemorrhage. The bleeding sometimes becomes an 
alarming complication. The voice becomes "flat" or "dead" in quality 
and respiration and deglutition embarrassed as the process advances. 
Pain and mucopurulent discharge appear later on. When the grow^th 
has attained considerable size the "frog face" becomes well marked, 
the maxillary bones are separated, and exophthalmos becomes a 
prominent symptom. Aprosexia and drowsiness are often present. 
In one of the author's cases the patient often dropped into sleep or slight 
stupor while in the treatment chair. Greville Macdonald reports 
vomiting as an annoying symptom. 



BENIGN NEOPLASMS ^ 353 

If the growth extends upward it may encroach upon the cranial 
contents and give rise to central symptoms, as paralysis, etc., followed 
in nearly every instance by death. 

The foregoing symptoms increase in severity as the growth extends, 
until the absorption of bony tissue is considerable, unless the tumor 
extends beyond the nasal and pharyngeal chambers, as into the cranial 
cavity. In this event the pressure necrosis of the bony tissue is not 
so great. 

Examination shows the tumor to be a rounded mass, of a pinkish or 
dark purple color. The veins are frequently varicosed, hence the examina- 
tion by digital or instrumental aids should be done carefully, so as to 
avoid injuring them. The growth may project into the posterior nares, 
or its direction may be toward the antrum and other sinuses. Under 
finger pressure it is firm and elastic, and if small its base may be out- 
lined. If pedunculated, it is movable, unless it has become fixed by 
inflammatory adhesions. If it extends through the sphenomaxillary 
fissure it may be felt under the zygoma. As adhesions are usually 
present, its outline is difficult to make out. 

Diagnosis. — The histological resemblance to sarcoma is often so close 
that a differentiation is difficult, unless the age, sex, and origin are such 
as to point to its fibrous nature. Sarcoma is rarely or never peduncu- 
lated, whereas fibroma is frequently pedunculated. 

Prognosis. — The prognosis is favorable in proportion to its early recog- 
nition and extirpation. It is also favorable as the age of the patient 
exceeds twenty-five years. In other words, small fibromata which do not 
fill the epipharyngeal space are more favorable under operative treatment 
than those which completely fill it. The tendency of the growth to 
undergo retrograde changes after the twenty-fifth year accounts for 
the more favorable prognosis in those cases appearing after this 
period. 

Some cases even undergo spontaneous recovery. It is advisable in 
nearly all cases to remove the growth by surgical interference, as it is too 
great a risk to wait for a spontaneous cure. An additional reason for 
operating is to relieve the patient as speedily as possible of the intense 
pain and other distressing symptoms characteristic of these growths. 

Treatment. — Small growths, especially if they are pedunculated, and 
those limited to the epipharyngeal space may be removed with a heavy 
snare or ecraseur, either through the nose or mouth. The galvano- 
cautery snare may even be used through these routes. When the growth 
is large and sessile, and has extensive inflammatory adhesions to the 
adjacent structures, it is necessary to perform an external or more radical 
operation. (See Operations for Fibroma of the Nose.) 

((/) Lipomata. — lipomata of the phar^oix are rare. When they occur 
they are usually small and sessile, esjiecially when they spring from dense 
tissue. When they spring from loose tissue they may attain large size, 
and are apt to be pedunculated and multiple. They are oval, smooth , and 
elast'c, hence are sometimes mistaken for retrophar^nigeal abscess. A 
puncture readily clears the diagnosis on this point. They usually occur 
23 



354 THE PHARYNX AND FAUCES 

in advanced age. Lennox BroA\ne says that the sessile and deeply 
seated ones are more often congenital than otherwise. 

(Ji) Angiomata. — Because of Crnveilhier's submucous plexus, situated 
at the back of the phar^aix, and the rather rich blood supply, both super- 
ficial and deep, we might naturally expect many angiomata. But, on 
the contrary, they are of rare occurrence. Moritz Schmidt does not 
cite a case in his excellent review of the tumors of the upper respiratory 
tract. Guyon cites one patient in whom digital examination caused 
profuse hemorrhage. Electrolysis checked the hemorrhage, and sub- 
sequently caused an atrophy of the growth. Angiomata of the pharynx, 
like similar growths elsewhere, are usually cavernous and often erectile 
in character. Farlow reports five cases of enlarged pulsating arteries 
in the phar}iix. The red-currant-like clusters are, strictly speaking, 
angiomatous. 

Treatment. — Most observers favor non-interference unless they bleed. 
There is some risk attending this attitude, as a serious hemorrhage 
may occur at any time. If large, they should be deprived of their 
arterial blood supply by ligatures applied to the efferent vessels supplying 
the tumor. If small, they may be treated by electrolysis or by ligation. 

Electrolysis is performed as follows: (a) Anesthetize with local 
applications of a 10 per cent, solution of cocaine. 

(b) Introduce the needles, connected with the positive pole of the 
galvanic battery, into the growth. 

(c) Turn on from 10 to 25 ma. of current for five minutes. Repeat 
the seances at intervals of about seven days until the growth is obliterated. 

The positive pole of the battery liberates nascent oxygen and coagu- 
lates the tissue, hence it should be the pole applied to a soft growth. 
If it is desired to reduce a hard or fibrous tumor, the negative pole is 
applied to the growth, as it liberates hydrogen, which softens the tissue. 

Ligation or strangulation may be performed as follows: (a) Anes- 
thetize by the local applications of a 10 per cent, solution of cocaine. 

{b) Pass a ligature through the tissues, including an artery at the margin 
of the angioma, and tie it. 

(c) Continue to thus tie off the larger vessels until the nutrient sources 
are closed. 

(d) After three or four days the ligatures should be removed. A cork- 
screw cleft palate needle is well adapted to the introduction of the sutures. 

MALIGNANT NEOPLASMS OF THE PHARYNX. 

General Pathology. — Clinically it is an advantage to make a distinct 
demarcation between the fauces and the pharynx in treating of malignant 
growths. However, as is well known, their tendency to spread by 
continuity of tissue and by metastasis, and their insidious beginning, 
does not permit of an ironclad anatomical division. Oftentimes they 
originate on the borderland between the two regions. It should be 
l)orne in mind that when these tumors spring from the larynx they are 
prone to extend to the pharynx, but that those arising from the pharynx 



MALIGNANT NEOPLASMS OF THE PHARYNX 355 

seldom, if ever, extend downward to the larynx. Even those occurring 
in the hypopharynx have an upward rather than a downward tendency. 
This is explained in part by the difference in the tissues composing the 
two parts. In the larynx there is little soft tissue, and the glandular 
element is less, whereas in the pharynx the soft tissues and lymph glands 
are more abundant. 

Embryologically the pharynx and the larynx have different origins, 
and the tendency to extension is thereby somewhat impeded. 

The general symptoms are much the same as in cancer of the larynx. 
The special symptoms are dependent upon the anatomical and physio- 
logical differences in the two regions. 

The lower portion of the pharynx is more often the seat of malignancy 
than the upper. Men are more often affected than women. Carcin- 
omata here, as elsewhere, are more frequent in the old. This is in 
obedience to the physiological law, that mesoblastic structures are 
more active in the young, while the epi- and hypoblastic structures are 
more active in the old. An effort is made by some writers to differentiate 
between the malignancy of sarcoma and carcinoma. This is of no 
practical or clinical value, as either is usually the cause of death in 
whomsoever it occurs. True carcinoma, because of its glandular struc- 
ture, more readily involves contiguous structures, and more frequently 
extends by metastasis. 

Carcinoma of the pharynx is more frequent than sarcoma. The 
former are more apt to involve the glandular structures, subjected as 
they are to persistent irritation, especially in the pharynx. Sarcoma 
may, however, be due to traumatism. 

It is often difficult to differentiate profuse scar tissue from sarcoma, 
as both are closely allied to embryonal tissue. The clinical phenomena 
are, therefore, often more reliable than the microscopic findings. 

Varieties of Sarcoma. — ^The various types of sarcoma which have 
made their appearance in the pharynx in their order of frequency are: 

1. Round-cell sarcoma. 

2. Spindle-cell sarcoma. 

3. Myxosarcoma. 

4. Lymphosarcoma. 

1. Round-cell Sarcoma. — ^The round-cell sarcomata are of two types, 
(a) large round-cell sarcoma, and (6) small round-cell sarcoma. Their 
structure is characterized by an aggregation of cells, intercellular cement, 
and numerous bloodvessels. Occasionally a few fibrous trabeculse are 
distributed through the mass of cells. Lymph channels are also found 
in the cellular masses. The cells vary considerably according to their 
age and original site of growth. The older part of the tumor is in a 
state of degeneration, while the newer part is intact. The small round- 
cell sarcoma is softer than the large roimd-cell growth, which has more 
intercellular cement substance. The cells of the large round-cell 
sarcoma often have oval nuclei, and are the most malignant of all the 
sarcoma. Its local ravages are extensive and the constitutional mani- 
festations are pronounced. 



356 THE PHARYNX AND FAUCES 

2. Spindle-cell Sarcoma. — This, like the round-cell variety, is divided 
into two classes, (a) small spindle-cell sarcoma, and (6) large spindle- 
cell sarcoma. The general structnre of this variety is quite like the 
round-cell sarcoma, except the cells are often arranged in bundles. 
Lymph spaces are absent, whereas they are present in the round-cell 
variety. The vascular supply is accordingly greater than in the round- 
cell variety. ^Nlany spindle-cell sarcomata have a tendency to imdergo 
degeneration in patches, and are less malignant than the round-cell 
variety. The spindle-cell sarcoma more often occurs in adults, while the 
rountl-cell variety is more often present in the young. The spindle- 
cell sarcoma develops slower than the round, is firmer, and less apt 
to ulcerate. It may be pedunculated, while the round-cell variety 
is seldom or never pedunculated. They are encapsulated and "shell 
out," while the round cell is not encapsulated. 

The local malignancy is greater than in the round-cell variety while 
the general malignancy is not so great. The spindle-cell sarcoma 
usually s])rings from the posterior wall of the pharynx, though it may 
arise from the lateral wall. 

3. Myxosarcoma. — The myxosarcoma is originally either spindle- 
or round-cell, which, having undergone an early mucoid change is 
converted into the myxomatous type. They are locally malignant, 
rather than constitutionally; that is, they have a tendency to recur, 
but seldom give rise to metastasis. They arise by preference in the 
loose cellular tissue of the lateral walls of the pharpix, though they may 
occur in the fauces and the glosso-epiglottic fold. 

4. Lymphosarcoma. — Lymphosarcoma is a variety of round-cell 
sarcoma. They possess a very delicate reticulum, giving them the 
appearance of a lymphoid structure. They usually orig nate in the 
lymphoid tissue of the pharpix, which is, perhaps, another reason for 
their resemblance to normal lymphoid or adenoid tissue. When the 
growth is traversed by numerous fibrous connective-tissue bands it is 
more dense in structure. It is necessary to differentiate this neoplasm 
from benign hyperplasia and lymphoma, which are directly due to in- 
flammatory processes. 

Lymphosarcoma grows rapidly, and when removed invariably recurs. 
They usually involve everything in their course, especially that type 
which starts in the lymphatic glands. Phar\mgeal lymphosarcoma ta 
are quite often observed in Hodgkin's disease, which is a true lympho- 
sarcoma. 



TRYPSIN TREATMENT OF MALIGNANT NEOPLASMS. 

The try|)sin treatment of malignant neoplasms is based upon the 
statistical findings of von Bergman, wherein he states (1) "that cancer 
of the stomach stops abruptly at the ]ndorus; (2) that the small intestine 
is but rarely the site of cancer; and (3) that cancer of the large intestine 
and rectum for the most part increases in frecjuency the farther the 



TRYPSIN TREATMENT OF MALIGNANT NEOPLASMS 357 

distance from the duodenum. In 10,537 cases of cancer of the ahmentary 
tract the stomach was mvolved 4288 times, the small intestine 20, the 
large intestine 224, and the rectum 1204 times. The natural and com- 
parative immunity of the duodenum and small intestine, together with the 
slower rate of growth of cancer of the large intestine, would, therefore, 
appear to support the treatment of inoperable cancer by preparations 
of the pancreas, bile salts, intestinal gland extracts, and ferments alone 
or combined. In November, 1905, Dr. Wade, at the solicitation of 
Dr. F. Beard, began experiments, first, to determine the action of trypsin 
upon the living cells of carcinoma, such as Jensen's mouse tumor (an 
adenocarcinoma); second, to test the truth of the conclusion advanced 
by Beard in 1902 that cancer was an irresponsible trophoblast; and third, 
the length of treatment and number of injections of trypsin necessary 
to destroy the tumor" (James T. Campbell). 

The results were such as to appear to show that the trypsin caused a 
degeneration of the cancer cells, a shrinkage of the tumor, and an 
improved condition of the system in general. Since then several cases 
of cancer in the human body have been reported wherein trypsin caused 
apparent shrinkage of the growth, a cessation of the pain, marked gain 
in weight, and great improvement in the health of the patients. It 
appears, however, that the improvement is but temporary, in some of 
the cases, a recrudescence of the neoplasm occurring later, with a rapid 
fatal termination. It is too soon to accurately judge the merits of the 
trypsin treatment. It is, however, worth the trial in inoperable cases. 
An operable case should always be operated in a most thorough 
manner. Delay and partial removal by operation are dangerous pro- 
cedures. An early operation and complete removal offer the best chance 
of a cure. The operation may be followed by the trypsin treatment. 

Technique of Trypsin Treatment. — The trypsin comes in sealed am- 
poules, of 20 minims each, of a glycerin extract prepared from the 
pancreatic glands, and with such a proportion of the ingredients of the 
normal salt solution that when diluted with two volumns of sterilized 
distilled water the medium corresponds in this respect to the normal 
salt solution; greater dilution may be employed if desired. 

x\t first 5 minims of the trypsin solution diluted with 10 minims of 
sterilized distilled water should be injected through the skin of the 
buttocks deep into the subcutaneous tissue, but not into the muscles. 
The injections may be given every other day, gradually increasing the 
(lose to 10 minims. 

The skin should be scrubbed with soap and alcohol, and in sensitive 
patients yV grain of eucaine may be injected a few minutes before the 
injection of the trypsin. 

Some writers recommend the administration of holadin in 3 grain 
ca])sules three times a day during the trypsin injections. Holadin is 
an extract of the entire ]ianci-eas gland, containing all the constituents 
of the digestive and the internal secretions of the gland. 



358 THE PHARYNX AND FAUCES 



THE EXCISION OF THE EXTERNAL CAROTID ARTERY AND ITS 

BRANCHES FOR INOPERABLE CANCER OF THE UPPER 

RESPIRATORY TRACT. 

The excision of both external carotid arteries and their eight branches 
may be performed for the purpose of depriving inoperable malignant 
growths of the nose and pharynx of their blood supply, thereby starving 
the growths. Malignant tumors require a large blood supply, hence 
this operation seems to offer some degree of hope. Daw^barn reports 
encouraging results in a number of cases of inoperable cancer of the 
head. The operation should never be performed wdien the grow^th can 
l^e successfully extirpated. The ligation of the external carotids and 
their branches should be adopted as a last resort. While it may not 
cure the case it may prolong life. 

The technique of the operation may be studied under the following 
heads : 

The Position of the Head.- — The shoulders should be placed upon a 
block or sand cushion, the chin well elevated and everted to the opposite 
side, so as to expose the region of operation to free access. 

The Incision. — ^The incision should extend from the tip of the mastoid 
process close behind the angle of the jaw^ to the level of the middle of 
the larjTix. At either extremity the incision is exactly over the external 
carotid artery. Dawbarn recommends that the incision be curved 
medianward about 1.5 cm., as the safety of the operation lies anterior 
to the artery, while danger lies posterior to it. 

Exposure of the Artery. — Work from below upward, first exposing the 
superior thyroid, which extends do\\Tiward to the thyroid gland. By 
tracing this back to the carotid the external is distinguished from the 
internal. Pass a chromicized catgut loosely around the external carotid. 
Examine the carotid and be sure that it bifurcates into the external and 
internal branches. If it does not it should not be ligated, as the blood 
supply to the brain w^ould be cut off and death result. 

If it does not bifurcate into the external and internal branches, only 
the branches supplying the external portions of the head should be ligated, 
the carotid being untied. Having determined that the common carotid 
bifurcates as usual, continue the dissection upw^ard, exposing each branch 
and tying it in two places and dividing it. The dissection is thus con- 
tinued upward until the level of the tw^elfth cranial nerve is reached, and 
all the branches of the artery but the terminal two have been controlled. 
The superficial carotid is itself tied twice and divided between. The 
ligature placed loosely around the external carotid below the superior 
thyroid branch should not be tied. It should not be tied sooner because 
the artery would collaj)se and render the dissection difficult. The 
ligature is placed in position early, ready for use in case of accidental 
hemorrhage in the course of the dissection higher up (Dawbarn). The 
upper portion of the artery should be dissected as it passes under the 
transverse loop of the twelfth nerve and the conjoined stylohyoid and 



THE EXCISION OF THE EXTERNAL CAROTID ARTERY 359 

posterior belly of the diagastric and on into the substance of (he parotid 
gland. It should be followed to its bifurcation when possible. The 
dissection should be done with a dissecting forceps or scissors and 
not with a sharp knife, as it might divide some of the lower branches 
of the pes anserinus and cause facial paralysis, or else, by cutting 
through some of the smaller ducts of the parotid gland, cause a salivary 
fistula (Dawbarn). Use gentle downward traction during the blunt 
dissection, and when as high as possible seize the artery with an artery 
forceps and tie above it as high up as possible and sever the artery below 
the forceps. 

Close the wound by sutures, leaving a rubber-tissue drain at its lower 
angle, or make a counteropening an inch and a half below the angle 
and insert the drain through this, entirely closing the original wound. 

At the end of five or six days the drain can be discontinued and the 
counteropening allowed to heal by granulation. 

Structures to be avoided: The internal jugular, internal carotid, 
pneumogastric, the superior laryngeal nerve, the pharyngeal branch of 
the pneumogastric, and the glossopharyngeal nerve. They all lie behind 
and deeper than the external carotid artery. Careful dissection should 
be done. 

The opposite carotid should be operated in like manner after an 
interval of ten days, though both may be done at one time if the patient 
is vigorous. 



CHAPTER XXI. 

DISKASES OF THE FAUCES AND TONSILS. 
THE TONSILS AS PORTALS OF INFECTION. 

Since Strassmann reported 13 cases of tuljerculous tonsils in 21 tuber- 
culous cadavers the tonsils have commanded considerable attention as 
channels of infection. The opinions of various observers since then 
have differed somewhat, especially in reference to the tuberculous pro- 
cess in the tonsils. There has been but little questioning of the fact, 
however, that the tonsils are portals of systemic and glandular infection. 
There is not, after all, a great divergence of opinion as to the tonsils 
being a much used highway of pathogenic infection, the seeming differ- 
ence being more a question as to certain details, rather than as to the 
general proposition itself. For example, some observers have failed 
to find tubercle bacilli, or the characteristic tuberculous changes in the 
tissue of the tonsils, which have been reported by other writers. Not- 
withstanding this, practically all writers agree that various pathogenic 
organisms do gain an entrance to the deeper tissue of the tonsils, the 
lymphatic glands, the lungs, the heart, and, indeed, to the whole system. 

In view of the growing interest and the exact information on this 
subject, the tonsils have gained a prominence in medical literature they 
did not have a quarter of a century ago. A brief resume of the current 
thought held on this subject wull, therefore, be given in connection with a 
study of the diseases of these organs. 

In reference to primary iuhercidosis of the tonsils, there is a divergence 
of opinion, some holding that the tubercidous process in these glands is 
direct, while others contend that the infection reaches them from the 
lungs through the lymphatics and the bloodvessels, or by the flow of 
the bronchial secretions over them. Both view\s are probably correct 
in selected cases. It is probable, however, that tuberculous infection 
of the cervical lymphatics glands is usually due to the entrance of the 
bacilli and other microorganisms thorough the tonsils. This is borne 
out clinically by the fact that suppurating or tuberculous glands of the 
neck are rarely found in phthisical patients. Whereas, if they occurred 
secondarily to ])ulm()nary infection they would be frequently found in 
such patients. 

That a latent tuberculous process may exist in the tonsils or in adenoids 
without |)resenting distinctive clinical signs thereof is suggested by the 
reports of a few cases in which a fatal pulmonary tuberculosis followed 
the removal of tonsils and adenoids. Friedrich suggests that the removal 
of the tonsils mav have excited a recrudescence of a latent tuberculous 



THE TONSILS AS PORTALS OF INFECTION 361 

tonsillitis in these cases. It seems to me that these cases point strongly 
to the conclusion that there is such a condition as latent tuberculosis 
of the tonsillar ring, which may continually infect the lymphatic glands 
of the neck, as well as the deeper structures in the thoracic cavity. Latent 
tuberculosis of the tonsils is not per se a serious menace to the health 
or the life of the patient, but the danger arises from the extension of 
the infection to the contiguous organs. 

The experiments of Dieulafoy show that of 96 guinea pigs inoculated 
with pieces of tonsils and adenoids, 15 developed tuberculosis. While 
these experiments are not conclusive in their scope or character, they are, 
nevertheless, suggestive. We know that tubercle bacilli are found on 
healthy mucous membranes, and it is possible, though not probable, 
that in these experiments the infection may have come from the accidental 
presence of surface bacilli. If it is admitted that the germs giving rise 
to the guinea-pig infection were within the tonsillar epithelial covering, 
we practically admit the major proposition, namely, that the tonsils are, 
or may become under favorable conditions, the portals of systemic or 
circumscribed infections in the contiguous glands and organs. In many 
instances it is also shown by the caseation or the suppuration which takes 
place in the tonsils. That there is not a close functional connection 
between the cervical and the pulmonary lymphatic glands appears 
clinically in the rarity of the extension of the tuberculous infection from 
the cervical lymphatics to the lungs. 

The facility with which the invasion of pathogenic microorganisms 
is accomplished through the tonsils depends upon the following factors : 

(a) The virulency of the invading microorganisms. 

{b) The pathogenicity of the microorganisms. 

(c) The general health of the patient. 

(d) The existence or the absence of the strumous diathesis. 

(e) The condition of the epithelium of the mucous membrane cover- 
ing the tonsillar crypts, and the condition of the tonsillar tissue. 

Piera has shown that bacteria are much more readily absorbed by 
the tonsils than is the coloring matter with which Goodale experimented. 
The germs pass into the interior of the tonsil, while the coloring matter 
is absorbed in the clefts of the lacunar epithelium. He also found that 
the pathogenic germs were more readily absorbed than the non-patho- 
genic, and that healthy tonsils absorb better than the fibrous. He does 
not intend to convey the idea, however, that healthy tonsils are a menace 
to the system, for, on the contrary, they are protective in function. While 
the healthy tonsil readily absorbs the pathogenic germs, it also has the 
power of destroying them. 

It has been thought that the tonsils are vestigial organs which once 
had a fimction that is now more or less obsolete. Packard has called 
attention to the fact that tonsils have been traced in the lower animals 
from the reptiles up to man; and that they are more complex in man, and 
cannot, therefore, be said to be vestiges. In this connection Watson 
Williams says: "But if the tonsils are in some measure a ])rotection 
against the invasion of microorganisms, their protective power is limited, 



:U\2 THE PHARYXX AXD FAUCES 

and once this limit is passed they are a positive source of danger. The 
crvpts and the fissures of the tonsils may become 'traps' for microbes, 
and the pecuhar anatomical arrangement of their investing epithelium, 
described by Stohr, opens the gates to their invasion into the tissues of 
the tonsil, whence through the lymphatic channels and vessels they may 
gain an entrance into the system; such systemic invasion by pathogenic 
microorganisms frequently occurs." 

Williams also refers to the researches by von Babes, wherein he proves 
that in pulmonary gangrene the infection may enter through the tonsils 
as well as through the bronchi. He also says, "Primary tuberculosis 
of the tonsils is less rare than is generally believed, and the failure of the 
faucial tonsils to arrest the development of the bacilli results in tuber- 
culosis of the cervical glands, so commonly observed in weakly children." 

Having thus referred to the tonsils as the atrium of infection for 
pathogenic microorganisms in general, and the tubercle bacillus in particu- 
lar, it remains to be said that it has long been thought that rheumatic 
fever has its origin in infection through the tonsils. Clinical observation 
certainly supports this view, as acute articular rheumatism is commonly 
observed following an attack of acute tonsillitis. 

Dawson advances the ingenious theory that scarlet fever has its 
primary lesion in the tonsils. Whether or not this view will be supported 
by future observations remains to be seen. It has been sho\ra by Kocher 
that acute suppurative osteomyelitis may be due to an infection by the 
same route. 

Acute tonsillitis is due to a local infection from streptococci and staphy- 
lococci, which are almost constantly present in the crypts of the tonsils. 

Wright and Walsham have failed to find the tuberculous process in 
removed tonsils, but this does not necessarily prove that they are not 
pathways of infection. I have already pointed out the fact that the 
tuberculous infection may exist in a latent form; that is, the bacilli may be 
present within the tonsillar follicles without giving rise to distinct histo- 
logical changes. By the term follicle is not meant the crypts or lacunae, 
but the lymphoid nodule. 

The lines of defeme against microbic invasions through the upper 
respiratory tract may be classified as follows : 

(a) The mucous secretions are regarded as having in some degree 
bactericidal properties. 

ih) The epithelial covering of the mucous membrane of the upper 
respiratory tract offers a mechanical barrier. 

{c) The lymphatic tissue composing Waldeyer's ring (tonsillar ring). 

id) The cervical lymphatic glands. 

(e) The bronchial lymphatic glands. 

(/) The endothelial lining of the bloodvessels. 

((j) The endothelial lining of the lymph vessels. 

(Ji) The serum of the circulating blood. 

(i) The leukocytes. 

It will l)e seen by the foregoing that the system is pretty well guarded 
against the invasion of pathogenic microorganisms. Should the first 



THE TONSILS AS PORTALS OF INFECTION 363 

or the second barrier be overcome, the remaining ones are still ready 
to bar the further progress of the morbific bacteria. 

In tuberculous infection of the cervical lymphatic glands the germs 
excite the reaction of mflammation, as shown by the enlargement of the 
glands. Under favorable conditions they are harmless on account of 
the phagocytic action of the leukocytes, which Stohr has shown are 
thrown out from the clefts in the epithelial covering of the crypts. 

Acute endocarditis, septic thrombophlebitis, and pyemic infarcts of the 
lungs have also been shown to be due to the absorption of microorganisms 
through the lymphatic ring. 

Recapitulation. — (a) Tuberculous tonsils have been found in subjects 
which died from tuberculosis. 

(6) Some observers have failed to find the tuberculous process in tonsils 
and adenoids removed from living patients, while others have been able 
to demonstrate it. 

(c) Primary tuberculosis of the tonsils, while not common, cannot be 
said to be rare. 

(d) Secondary tuberculosis of the tonsils has been demonstrated. 

(e) Latent tuberculosis may exist in tonsils and adenoids without 
presenting distinctive clinical signs. 

(/) The removal of tonsils and adenoids is sometimes followed by 
pulmonary tuberculosis. 

(g) There are several barriers to the invasion of pathogenic micro- 
organisms into the system. 

{h) The invasion of the pathogenic microorganisms is favored by the 
virulency of the germ, and by certain local and constitutional conditions. 

(i) The tonsil is a barrier against the invasion of microorganisms, 
and its power in this capacity is limited by the age of the patient and the 
condition of the tonsil. 

(j) Rheumatic fever, acute endocarditis, septic thrombophlebitis, 
pulmonary gangrene, and other infective conditions have their initial 
lesions in the tonsils. 

Practical Applications. — In view of the facility with which micro- 
organisms, especially of the pathogenic type, gain entrance into the 
system through the tonsils, it becomes necessary under certain conditions 
to remove the tonsils in their entirety 

I have seen cases in which repeated attacks of acute. follicular tonsillitis 
and concurrent cervical lymphadenitis had taken place. After tonsil- 
lectomy, i. e., the complete removal of the tonsils, the tonsillitis necessarily 
ceased to recur, and there was no further recurrence of the lymphadenitis. 
It may be logically concluded that the tonsils acted as a permanent 
incubator for the streptococci and the staphylococci, and the incubator 
being removed, the cervical lymphadenitis disappeared. 

When the latent tuberculous process is present in the tonsils, the cervical 
glands are infected and give rise to the repeated enlargement and case- 
ous degeneration of the glands. After the complete ablation of the 
tonsils, including the capsule, great improvement of the glandular dis- 
ease should occur. While it may not always be advisable to perform 



364 THE PHARYXX AXD FAUCES 

tonsillectomy, it is usually well to do so in those cases with enlarged 
cervical glands. 

It is also advisable to perform complete ablation when there is an active 
tuberculous process in the tonsils with an incipient involvement of the 
lungs. I have removed tonsils in this condition with the most satis- 
factory results. 

Singers and jniblic speakers with a troublesome subacute laryngitis, 
and whose tonsils are small and fibrous, or enlarged, may be benefited 
l)y the complete ablation of the tonsils, ther by relieving a possible 
source of irritation of the larynx through the absorpt on of microorgan- 
isms and septic matter. 



THE CLINICAL ANATOMY OF THE TONSIL. 

The tonsil (Fig. 233) is situated in the sinus tonsillaris between the 
faucial pillars, and has its origin in an invagination of the hypoblast at 
this point Later the depression thus formed is subdivided into several 
compartments which become the permanent crypts of (he tonsil. Lym- 
phoid tissue is deposited around the crypts, and thus the tonsillar mass 
is built up. The inner or exposed surface including the cryptic de- 
pressions, is covered with mucous membrane, while the outer or hidden 
surface is covered by a fibrous capsule. 

According to Landois and Stirling, the development of the palatal 
tonsil is most easily studied in the rabbit, where the single primary 
crypt generally remains without branches through life, and there the 
tonsil first appears in embryos f inch long (occipitosacral measure- 
ment), or of about twelve days as a shallow epithelial fold whose apex 
points directly backward into the connective tissue concentrically 
condensed around the pharpix. At this stage there is no infiltration of 
the leukocytes in the connective tissue around the crypt, and it is not 
until the embryos are about twenty-one days old (1^^ inches long) that 
the leukocyte infiltration becomes evident. The crypt has then become 
much deeper and broader, and by its ingrowth has produced a condensa- 
tion of the connective tissues at right angles to the original peripharyngeal 
condensation, as well as a great increase in the number of capillary 
bloodvessels. From this stage the elongation of the crypt, the condensa- 
tion of the connective tissue, the increase in the number of bloodvessels 
and in the amount of leukocyte infiltration go on jmri jyassu until the 
adult condition is I'eached. As soon as the leukocytes appear in number 
in the submucous tissue they proceed to wander through the epithelium, 
as Stohr has described. 

In the fetus of the pig the condensation of the connective tissue, 
especially at the apex of the tonsillar crypts, and the consequent massing 
of leukocytes, mainly at these points, is particularly well showm. 

In the human fetus the process is the same, though complicated by 
the early ramification of the original epithelial crypt and the ajipearance 
of fresh ones. The crypts become so deeji that the cells from the surface 



THE CLINICAL ANATOMY OF THE TONSIL 365 

layers of their epithelium cannot at once be thrown ojff into the mouth, 
and remain as a concentrically arranged mass of degenerated cornified 
cells filling up the lumen of the crypt; this mass is ultimately forced out 
by the vis a tergo of the leukocytes emigrating through the epithelium. 
It will at once be seen how closely this resembles the formation of the 
concentric corpuscles of the thymus. The tonsils are preserved from the 
face of the epithelial thymus by retaining their lumen. 

The prime factor in the formation of the tonsils is the epithelial 
ingrowth, which partly mechanically compresses the meshes of the con- 
nective tissue, and partly causes proliferation of the connective cells 
and vessels by the slight irritation it produces, thereby making it easier 
for the leukocytes to escape from the thin-walled capillaries and veno- 
capillaries so formed, and, when they have escaped, causing them to be 
detained in the finely meshed connective tissue longer than in other 
situations. As the leukocytes are well supplied with nutriment, they 
divide by mitosis here in large numbers, as Flemming and his pupils 
first showed, and at a late stage in development (with great variations 
in individuals) "germ centres" are formed, where a special arrangement 
of connective tissue and vessels favors the process of division. 

The lingual and pharyngeal tonsils develop in the same way as the 
palatal. His shows that all the tonsils arise behind the membrana 
pharyngis, and, consequently, all these epithelial ingrowths pass into 
connective tissue already condensed around the primitive alimentary 
canal (G. L. Gulland). 

It will be observed that the tonsil is an encapsulated organ, and that it 
is characterized by from eight to twenty crypts or tubular depressions. 
Many practitioners have confused the tonsil with the follicular tissue im- 
mediately surrounding it. So long as they were able to remove follicular 
tissue through the wound in the sinus tonsillaris, they thought they were 
removing tonsillar tissue. In this they were mistaken, as the lymphoid 
tissue immediately surrounding the tonsil is not encapsulated, nor is it 
characterized by cryptic depressions. 

The tonsil does not always completely fill the sinus tonsillaris, the 
unoccupied space above it being known as the supratonsillar fossa, 
into which several crypts usually open. 

The outer aspect of the tonsil is loosely attached to the superior con- 
strictor muscle of the pharynx, thus subjecting it to compression with 
every act of deglutition. The palatoglossus and palatophar}aigeus 
muscles of the pillars also compress the tonsil. Grober cites authorities 
who claim that the compression of the muscles forces food and bacteria 
into tlie ci-ypts. 

The Crypts. — The crypts are usually tubular and almost invariably 
extend the entire depth of the tonsil to the capsule on its outer surface. 
Some, however, are compound, i. e., they divide below the surface into 
two or more tubules. They are usually comparatively straight, though 
they may be tortuous in their course. I have examined many tonsils 
removed with the capsule intact, and have rarely found crypts that did 
not extend through the follicular tissue to the capsule. Those opening 



366 THE PIIARYXX AND FAUCES 

in the supra tonsillar fossa usually extend downward and outward, 
whereas in the lower portion of the tonsil their direction is outward. 
The area occupied by the mouths of the supratonsillar crypts constitutes, 
according to Killian, the hilus of the tonsil. Clinically, the crypts seem 
to be the source of the greatest amount of local and constitutional disturb- 
ances, as they often become filled with food, tissue debris, and bacteria. 
This is especially true of those capped over by an overlying membrane, 
as in the supratonsillar space, and the antero-inferior portion of the tonsil 
which is covered by the plica triangularis. The plica supra tonsillaris 
(Fig. 233) does not, in all cases, enfold the hilus, or supratonsillar crypts, 
as the tonsil often fails to fill the supratonsillar space. In other instances 
it closely hugs the u])per end of the tonsil, thereby completely closing 
the mouths of those crypts. It is in these cases, particidarly, that the 
contents of the crypts are retained. This is also true in reference to 
those covered by the plica triangularis. 




The anatomical landmarks of the tonsillar region, a, margosupratonsillaris; b, the supraton- 
sillar fossa; c, hilum of the tonsil, the slit-like crypts of the tonsil in the supratonsillar fossa; d, 
anterior pillar of the fauces; e, phcatonsillaris (hyperculum pHcatriangularis) ; f, posterior pillar 
of the fauces; g, a large crypt near the base of the posterior pillar, which often becomes closed, 
and gives rise to infection and inflammation. 

Reasoning from a mechanical point of view, one would reach the 
conclusion that the retention of the infected secretions must necessarily 
give rise to infectious inflammatory processes. Clinically, we know 
that this is not true. The crypts are often found filled with food, tissue 
debris, and pathogenic bacteria, without any appreciable inflammatory 
reaction. Nevertheless, as I shall exemplify later, the mechanical 
closure of the crypts by the plica supratonsillaris and the plica triangu- 
laris adds greatly to the tendency to inflammatory and other morbid local 
and general processes. 

It may be stated as a general law in physiological pathology that 
mechanical obstruction to the drainage of any secreting cavity tends to 
result in local morbid processes and in toxic or infectious manifestations 
in remote parts of the body. " 

The Epithelium. — The free surface of the tonsil, including the crypts, 
is covered with stratified pavement epithelium, the deeper layers of 
which are columnar in type, while the superficial are pavement. Goodale 



THE CLINICAL ANATOMY OF THE TONSIL 367 

has shown that certain coloring matter, when dusted in the crypts, is 
readily absorbed into the interior of the tonsil. He claims that the 
absorption probably takes place through the interspaces between the 
cells. From this the inference might be made that bacteria are absorbed 
with equal facility. This conclusion does not, however, coincide with 
either physiological or clinical data. 

Jonathan Wright has shown that there is a vast difference in the 
absorptive power of the tonsil for dust and for bacteria. Wright introduced 
carmine pow^der and bacteria into the crypts of the tonsils and excised 
them in fifteen minutes. The microscope showed the carmine particles 
in great abundance beneath the epithelium and within the intercellular 
spaces, whereas no bacteria were found. He also observed that the 
carmine dust remaining on the outside of the tonsil was easily washed 
away, while the bacteria were more difficult to remove. The adherence of 
the bacteria to the live animal membrane and their failure to pass through 
it he ascribed to the viscosity of the bacteria, a biomechanical property 
of microorganisms. The mechanical affinity existing between the 
bacteria and a living mucous membrane he considered as one of their 
defensive and offensive properties of a biomechanical kind, as distin- 
guished from their biochemical products, the toxin and endotoxin. Dust 
or carmine powder does not possess this adhesive property, hence it is 
readily absorbed, whereas the bacteria are not. 

We know, however, from abundant clinical experience, that there are 
conditions under which the bacteria are absorbed through the cryptic 
epithelium in sufficient numbers to excite marked local and constitutional 
disturbances. Apparently the adhesive property of the bacteria has been 
overcome, or the toxin of the microorganisms within the crypts has con- 
verted the live epithelium into inert matter, through which it readily 
passes. Wright says: "From the experiments of Goodale and others 
with colored granules, from my own observations of dust particles 
passing the epithelial layer in health, and bacteria passing it in diseases, 
it is evidence enough that there must be something beyond mechanical 
obstruction which, under ordinary conditions of health, keeps the tissue 
beneath the epithelium free of bacterial life, which swarms in some of 
the crypts on the outer side of the epithelial cells. Hitherto the revela- 
tions of the antitoxic power of the blood sera have been insufficient to 
explain the problem. That explains the nullification of the toxic power 
of the pathogenic germ after it passes within the tissues, but it does not 
explain immunity from infection — to translate literally, the freedom 
from the carrying in of the germ. It seems probable from experimenta- 
tion with various forms of protoplasm that the animal organism evolves 
defensive properties to destroy by lysis, when the system through lack 
of excretory power becomes embarrassed by their presence." 

Wright further says that "bacterial protoplasms may excite bacterio- 
lytic ferments in the epithelial cells, a j^roperty heretofore referred by 
Metchnikoff to the leukocytes only." In these ways he attempts to 
show equililirium existing between immunity and infection. An im- 
balance of this equilibrium is effected by a loss of local tonicity or health, 
and infection then takes place. 



368 THE PIIARYXX AXD FAUCES 

In the epithelial linino- of the ervpts we fiiul, therefore, the following 
properties : 

(a) A biomechanieal rcsistanee to the invasion of the microorganisms, 
viscosity. 

(6) A hioehemieal destruction or taming of the microorganisms in 
the crypts through the agency of a ferment thrown out by the epithelium 
under the stimulus of the retained bacteria. This process is known 
as bacteriolysis. 

So long as the epithelium of the crypts is in a state of tonicity or health, 
an ecjuilibrium between immunity and infection is maintained. When 
the cellular tonicity is impaired, the equilibrium between immunity 
and infection is lost and infection occurs. When the crypts are closed 
by the plica supratonsillaris and phca triangularis, or by concretions in 
the mouths of the crypts, a very active warfare between the retained 
microorganisms and the epithelial cells is begun. The cells throw out 
a poisonous ferment, whereas the bacteria throw off a toxin for the pur- 
pose of impairing the tonicity of the epithelium. If the siege is continued 
sufficiently long, the cells give way and the infectious host penetrates 
the epithelial barrier and enters the deeper tissues of the tonsil. 

The Sinus Tonsillaris. — The anterior pillar contains the palatoglossus 
nuiscle and ft)rms the anterior boundary, whereas the posterior pillar 
contains the palatopharyngeus muscle and forms the posterior boundary 
of the sinus. The pillars meet above to unite with the soft palate. 
Inferiorly they diverge and enter into the tissues at the base of the tongue 
and the lateral wall of the phar}aix respectively. The outer wall of the 
sinus tonsillaris is composed of the superior constrictor muscle of the 
pharynx. The sinus tonsillaris is, therefore, a triangular depression 
on the lateral wall of the fauces which partially envelops the tonsil. 

In so far as my clinical observations show, the tonsil is loosely attached 
to the sinus, that is, the so-called adhesions are not present. The 
extent of the attachment varies in different subjects. Patterson has 
shown that the supratonsillar fossa may extend dovtaiward so as to admit 
a bent probe between the outer side of the tonsil and the superior con- 
strictor muscle of the pharynx, as far as the inner surface of the lower 
jaw. Even when the attachment is general it is not usually so firm 
as to greatly interfere with the enucleation of the tonsil. The "adhesion" 
to the anterior pillar so often spoken of is, in my opinion, a myth. It 
is true that the tonsil has an anatomical connection with the anterior 
pillar, but the union is not of that firm, fibrous nature usually implied 
by the term. Indeed, the term "adhesion" is often used in reference 
to the plica triangularis which covers the antero-inferior portion 
of the tonsil, and which is often attached to the tonsil at its inferior 
extremity. One writer even s})eaks of the plica triangularis as an hyper- 
trophy of the anterior pillar, whereas, in fact, it is an embryological struc- 
ture, which in some of the lower animals develops into the tonsil itself. 

The anterior limit of the sinus tonsillaris often extends well under the 
anterior pillar, thus concealing a large portion of the tonsil. The outline 
of the tonsil may be readily determined by digital examination or by 



THE CLINICAL ANATOMY OF THE TONSIL 



369 



seizing it with forceps and drawing it toward the median Une of the 
throat. When thus drawn the anterior shoulder of the tonsil may be 
seen outlined beneath the anterior pillar, and if still more forcibly drawn 
inward, the tonsil mass slips from beneath the pillar, thus showing that 
it is not markedly adherent, but that, on the contrary, it is loosely 
attached and by proper procedures may be readily enucleated. 

The Lymphatics. — The relation of the tonsil to the lymphatic vessels 
is somewhat different from that existing between the lymphatic gland 
and vessels. The difference in the relationship consists in the fact that 
the lymphatic vessels have their origin in the tonsil, whereas they pass 




Schema of the lymphatic communications with the teeth, tonsils, adenoids, and mastoid 
region. Tlie mastoid glands flow into the posterior chain of glands; the adenoids into both the 
posterior and anterior chains; the tonsil into the anterior group only; the dental glands into 
the anterior group, though in violent inflammations of the neck glands the current may be 
reversed. (After Eisendrath.) 



through the lymphatic gland. The question of chief clinical importance 
is the course and termination of the tonsillar lymphatic vessels which 
drain into the deep cervical chain underneath the sternocleidomastoid 
muscle, and from thence to the thoracic glands, and finally into the 
thoracic duct. By this route infection is carried to all parts of the body. 
The tonsil, untler certain conditions, being peculiarly susceptible to 
infection, becomes, therefore, the atrium of infection for a great variety 
of diseases extraneous to itself. The literature is rich WMth clinical 
reports of diseases illustrating this fact (Fig. 2.34). 

In reference to the tonsil as the portal of infection in tuberculous 
24 



370 'I'JfJ'^ PJIARYXX AXD FAUCES 

processes, it is f^enerally admitted that it often takes place through the 
tonsil, and extends from thence through the lymphatics of the deep 
cevrical chain on into the thorax. It then passes through the hilus of 
the lung into the visceral pulmonary lymphatics. The apex of the right 
lung is the most frequent seat for the inception of the pulmonary tuber- 
culous disease. This has, heretofore, been attributed to the fact that 
this area is less directly in line with the respiratory air current, and that 
this portion of the lung has less motion than other portions of either lung. 
It forms, therefore, a ])(H-uliarly favorable locat on for the development 
of the tubercle bacillus. 

Dr. J. Grober has called this loute of pulmonary infection into cjuestion, 
or at least he has set up a rival hypothetical explanation, based upon a 
series of experimtnts upon lower animals. He reports the following 
three suggestive experiments out of a total of twenty-eight: 

First experiment, September lb, 1902. A young rabbit was anesthe- 
tized by ether and chloroformed, and 1 c.c. of a sterilized emulsion of 
black Chinese paint injected into the left tonsil. 

September 23, 1902, the autopsy showed black particles in the blood. 
Behind the left tonsil there was a mass composed of the coloring matter 
and leukocytes. The lymph glands on left side of the neck, as far as the 
upper border of the thyroitl cartilage, were stained black. The micro- 
scope demonstrated the lymph vessels filled with free coloring matter, as 
well as leukocytes which enclosed small particles of pigment. 

The glands and lymph vessels were fairly packed with the coloring 
matter. Beyond the zone of the lymph glands and vessels little coloring 
matter was found. 

Second experiment. A small dog was narcotized by morphine injec- 
tions. Six and one-half c.c. of the sterilized emulsion of l)lack 
pigment was injected into the tonsil. 

The autopsy, after complete exsanguination, showed the following 
conditions: Very little coloring matter in the leukocytes, none being free 
in the blood. The tonsil and the loose connective tissue containing 
the afferent lymphatic vessels of the tonsil were of a deep black color. 

Along the muscles of the neck, as far as the hyoid bone and to the 
median line, there were streaks of pigment. The pigmented area also 
spread downward below the hyoid bone, where it extended 1 cm. beyond 
the median line. The coloring matter was traced to the bony opening 
of the thorax and to the par'etal pleura, which, when stripped off and 
examined by transmitted light, showed the black pigmentation. The 
lymph vessels of the para tracheal connective tissue and of the esophagus, 
as far as 2 or 3 cm. above the l)ifurcation of the trachea, were also 
colored, whereas on the left or iminjected side no such phenomenon 
was found. All the lymph glands on the lateral wall of the pharynx, 
hyoid bone, larynx, along the deep vessels of the neck and supraclavicular 
fossa on the right side were black. The parietal pleura at the apex 
showed an exudate, but no adhesioii to the visceral pleura. 

"^I'lie microscojje showed that in all the above-mentioned positions 
there were no other changes })rcsent. In the glands the coloring matter 



THE CLINICAL ANATOMY OF THE TONSIL 37I 

occupied the paravascular spaces. In the lymph vessels between the 
supraclavicular glands and the parietal pleura of the apex there was a 
large number of leukocytes filled with coloring matter. Free coloring 
matter was also present in this region. In the apex of the lung there 
were no signs of an inflammatory reaction. The coloring matter here 
seemed to be freely deposited within the connective tissue. In the above- 
mentioned exudate at the apex there was coloring matter in the leukocytes. 

Third experiment, April 4, 1903. A small dog was placed under 
morphine narcosis and 5 c.c. of coloring matter injected into the tonsil. 
April 13, the same experiment was performed on the opposite side. 

May 10, the autopsy, after exsanguination, showed a large amount of 
coloring matter free in the blood; the leukocytes, the tonsil and connec- 
tive tissue, and the connective tissue of the neck on both sides along the 
lar^aix to the aperture of the thorax were colored symmetrically. The 
lymphatic glands along the large bloodvessels, as well as those in the 
supraclavicular region, were deeply stained. The coloring matter was 
also found within the lymphatic vessels and in the paravascular spaces. 
A fibrous exudate was found in the apices of both lungs, thus forming a 
bridge of inflammatory material from the parietal to the visceral pleura. 
The coloring matter was also present in the exudate. The microscopic 
appearance of the apices presented a light grayish coloration. The 
glands in the mediastinum were stained on the left side, as were also the 
bronchial glands. In the left lung there were three other small fibrinous 
exudates in which the coloring matter was preseni. 

From these experiments Grober builds the hypothesis that tuberculous 
infection of the apex of the lung may take place via the deep lymphatic 
chain, the supraclavicular glands, and thence to the parietal lymphatic 
vessels, where an inflammatory exudate is thrown across to the visceral 
pleura. The tubercle bacilli travel across this inflammatory bridge and 
enter the apex of the lung. 

While these experiments are not conclusive, they are interesting and 
open a field for further observations. 

The Blood Supply. — The tonsillar artery, a branch of the facial, is 
the chief vessel to the tonsil, though the ascending palatine, another 
branch of the lingual, sometimes takes its place. The tonsillar artery 
passes upward on the outer side of the superior constrictor muscle, 
through which it passes and gives off branches to the tonsil and soft 
palate. The palatine, another branch of the lingual, also sends branches 
through the superior constrictor muscle to the tonsil. The ascending 
pharyngeal also passes upward outside of the superior constrictor, and 
when the ascending palatine artery is small it gives off a tonsillar branch 
which is correspondingly larger. The dorsalis linguse, a branch of the 
Ungual artery, ascenfls to the base of the tongue and sends branches 
to the nostril and pillars of the fauces. The descending or posterior 
palatine artery, a branch of the inferior maxillary, supplies the tonsil 
and soft pahite from a])ove, forming anastomoses witli the asccinHng 
palatine. The small meningeal artery sends more bvaiielies to llie tonsil, 
though they are of minor importance. 



372 THE PJIARYXX AND FAUCES 

Clinical Application. — Without rcviewino; the literature, which is 
rich iu reports of cases showing the tonsil to be the portal of infection 
for many diseases in remote parts of the body, I have attempted to 
show under w^hat conditions it becomes the portal or atrium of infec- 
tion. Under conditions of local equilibrium or health of the epithe- 
lium lining the tonsillar crypts, infection does not take place, whereas, 
when the local equilibrium is lost, infection occurs. That the local 
equilibrium of the cryptic epithelium is frequently lost is apparent to 
every clinician. In addition to the diseases arising through the tonsil as 
a portal of infection, there are those limited to, or having their focal 
centre in, the tonsil itself. Perhaps the strongest indictment against the 
tonsil is that it is often the atrium of infection in pulmonary tuberculosis. 
Whether the route of infection is via the deep lymphatics and the hilus 
of the lung, or the deep lymphatics and the parietal pleura at the apex, 
as showTi by analogy in the experiments of Grober, is immaterial in so 
far as the general question is concerned. The question of prime im- 
portance is, Do pulmonary or other types of tuberculosis have their 
origin through the tonsil as a portal of infection? In view of my own 
observations, and of others, I must answer in the affirmative. Just what 
])ercentage has not been fully determined. Various writers report 
from 4 to 10 per cent, of tonsils removed as showing local tuberculous 
lesions, as tubercle bacilli and giant cells. 

The structures of the tonsil which seem to favor infection are the 
crypts, especially those in the supra tonsillar fossa and those covered 
by the plica triangularis. Wright has suggested that the imperfect 
drainage of the crypt leads to the ultimate loss of tonicity (equilibrium) 
in the epithelial cells lining them, thereby opening the way to systemic 
infection through the tonsil. 

The question naturally presented at this juncture is, What is the 
rational method of procedure to protect the system from further infection ? 
The choice of remedial measures seems to lie between internal medica- 
tion, local applications, and surgical interference. 

As to the first and second methods of treatment, it may be said that 
there are cases which may be satisfactorily treated by them, especially 
in relieving the distressing local inflammatory symptoms; indeed, many 
cases may be practically cured by such treatment. There are many 
others, however, in which such measures are wholly inadequate, either 
to relieve immediate symptoms or to ward off future attacks. In these 
cases we have usually resorted to some surgical procedure, such as open- 
ing the crypts, plunging the cautery point obliquely across them, de- 
caj)itati()n (partial removal of the tonsil), and the complete removal of 
the tonsil. 

The literature shows a wide divergence of opinion as to what consti- 
tutes the best method of surgical treatment, though it shows nearly all 
writers as being'practically agreed that some sort of surgical procedure is 
indicated. 

What does the anatomy seem to indicate? It shows certain crypts 
so situated as to afford poor drainage of their contents, even though the 



THE CLINICAL ANATOMY OF THE TONSIL 373 

superior constrictor, palatoglossus, and palatopharyngeus muscles com- 
press the tonsil with each act of deglutition. This is especially true of 
those crypts dischargmg into the supratonsillar fossa. Kauffmann has 
suggested that the supratonsillar crypts be opened with a sharp knife, 
and that the incised surfaces be painted with 5 to 20 per cent trichloracetic 
acid. By this opening of the crypts their contents are drained. The 
acid applications excite a violent inflammatory reaction which results 
in the contraction of the tonsil tissue. The process is often an extremely 
painful one, and may result in cellulitis and scar tissue. Furthermore, it 
does not always prevent further infection through the tonsil. It is, 
therefore, often necessary to repeat the incisions and acid applications. 

The patient is entitled to immunity from tonsillar infection if it can 
be established without seriously jeopardizing either his health or life. 
When the tonsil becomes a w^ell-established atrium of infection, the 
physical economy of the patient is constantly menaced by conditions 
ranging all the way from a follicular tonsillitis to endocarditis and pul- 
monary tuberculosis. Measures should, therefore, he adopted which 
will ensure future freedom from infection through the tonsil. 

It has been sho^ii by abundant clinical experience that cauterization 
of the lumen of the crypts or obliquely across them into the surrounding 
follicular tissue, does not adequately meet the indications. 

The same is true of "decapitation," or partial removal of the tonsil. 
Decapitation leaves the deep and more diseased portion of the crypts, 
and, while it may afford some relief of the symptoms, it is often followed 
by recurrent infections and by the reformation of the tonsillar tissue. 

The complete removal of the tonsil with its capsule intact is, so far as 
I know, the only mode of surgical procedure that guarantees immunity 
from infection through the sinus tonsillaris. 

The function of the tonsil and the effect of its complete removal 
upon the general condition of the patient must be considered; so, also, 
must the question of hemorrhage. In reference to the effect of the 
removal of the tonsil upon the general system, it may be said that there 
is little evidence that it has any deleterious result. Masini, however, 
believes that the tonsil has an internal secretion comparable with that 
given off by the suprarenal gland. He arrived at this conclusion after 
experiments with the aqueous extract of the tonsil, intravenous injections 
of which gave the same results as obtained from the injection of supra- 
renal extract. 

The last word concerning the treatment of the tonsil cannot be spoken 
until its exact function is established. Clinically, there is little to show 
evil effects from its removal, wliereas there is much evidence to show the 
good resulting from its removal, especially its complete removal. 

I have attempted its complete removal with the capsule intact in 
al)out 2000 cases during the past six years, and, barring one or two 
instances in which there was a temporary paresis of the palatophar^iigeus 
muscle, one case of cervical cellulitis, and a half-dozen moderate hemor- 
rhages, I have seen no untoward result. The general health of many 
Wiis greatly improved and recurrent sej)ti(r inflanunation within the sinus 



374 THE I'/fAh'VXX AM) FAUCES 

tonsillaris has been eliniinated. Recurrence of the tonsillar tissue has not 
taken })lace in a single instance. The fact of its regrowth is almost 
prima facie evidence that the entire tonsil was not removed. I will not 
attempt to deny that follicular tissue can be removed from the sinus 
tonsillaris after the complete removal of the tonsil, and that follicular 
tissue may develo}) within the sinus tonsillaris. But this should not be 
mistaken for the recurrence of the tonsil. The tonsil is an encapsulated 
mass of lymphoitl tissue characterized by numerous crypts. 

Having removed the entire tonsil with its fibrous envelope, and its 
crypts, the chief source of infection is removed. It is, of course, possible 
for the follicular tissue which surrounds the tonsil to become diseased, 
but this should be differentiated from tonsillar disease. When the 
tonsil is not removed with its capsule intact, it is, of course, impossible 
to determine whether it has been entirely removed ; and if a part of it is 
left, regeneration might well take place. With these facts in mind, it 
is aj^parent that the complete removal of the tonsil should show a 
distinctly defined mass of lymphoid tissue enveloped within a fibrous 
capsule on its outer, and with mucous membrane on its median, aspect. 
Lymphoid tissue which is not thus characterized is not tonsil tissue. 

Hemorrhage. — The danger from hemorrhage is, perhaps, the greatest 
"bugbear" of the operation. Is this a real or an imaginary obstacle? 
It is both. It is real in so far as severe hemorrhage does occasionally 
occur in tonsil operations. It is imaginary in so far as the reputed 
frecjuency of its occurrence and the degree of the danger attending it. 
A clear knowledge of the possible sources of hemorrhage will enable 
the operator to largely exclude its occurrence. Furthermore, there are 
certain matters in the teclinique of local anesthesia, and in the after- 
treatment, wdiich, if properly applied, will greatly reduce the frequency 
and amount of hemorrhage. Clinically, I have observed that the most 
frequent site of arterial hemorrhage is at about the middle portion of 
the sinus tonsillaris, where the tonsillar branch of the facial pierces the 
superior constrictor muscle of the pharynx. Other points of hemorrhage 
are usually limited to the inferior portion of the sinus tonsillaris, where 
the tonsillar venous plexus is located, and to the anterior and posterior 
pillars. 

In another part of this chapter I have referred to the fact that three 
arteries, the tonsillar, the ascending palatine, and the ascending pharyn- 
geal, pass upward on the outside of the superior constrictor nuiscle, which 
they pierce as they tin-n inward to ramify the tonsil and faucial pillars. 
Just before entering the tonsil they break up into several l)ranches 
(Fig. 235). It is obvious that the smaller the branches cut during an 
operation, the less serious the hemorrhage. The clinical application of 
this fact is that if the arterial branches are severed as they enter the 
capsule of the tonsil, the liability to hemorrhage is reduced to the mini- 
nnun; whereas, if they are severed on the outer aspect of the superior 
constrictor muscle before they are broken up into smaller branches, 
the danger from both primary and secondary hemorrhage is greatly 
increased. It may be said that the operator should not injure the 



THE CLINICAL ANATOMY OF THE TONSlL 



375 



superior constrictor muscle in this operation, and this is true. Indeed, 
if he thoroughly appreciates the clinical significance of the anatomy of 
the tonsillar region, he probably will not injure it. There's the rub. 

As to the anterior pillar, it should be borne in mind that there are 
arterial twigs coursing upward through it. The main trunks of the 
arterial branches are external to the palatoglossus muscle. Hence it 
follows that in order to injure them it is necessary either to pass the 
instrument behind the muscle, and thus injure them, or to include the 




n, subdivisions of tlie tonsillar artery; b, superior constrietor muscle of the pharynx; c c, 
fibrous capsule of the tonsil: d, lymph follicles or substance of the tonsil; e, plica supratonsil- 
laris; /, supratonsillar fossa. 



musculature of the anterior pillar in the grasp of the tonsillotome, knife, 
l)lunt dissector, or scissors, etc., and thus sever the muscle and vessels 
of the anterior pillar. The same statements may be made in reference 
to the posterior pillar. 

The technic[ue should, therefore, be such as to avoid injury of the 
muscles bounding the sinus tonsillaris, namely, the superior constrictor 
of the pharynx, the palatoglossus and the palatopharyngeus muscles, as 
by so doing only the small branches of the tonsillar arteries are injured. 



CHAPTER XXII. 

THH IXFr.AMMATORY DISEASES OF THE TONSIL. 

General Considerations. — The inflammatory diseases of tlie tonsils 
are usually subdivided into various types, according to whether the 
process is acute or clironic, and is limited to the crypts or extends to 
the substance or parenchyma of the tonsil. As a matter of fact, this 
classification is somewhat artificial, as it is now well established that all, 
or nearly all, inflammations of the tonsil are due to infection through the 
epithelium of the crypts. The manifestation may be acute or chronic 
in type; it may appear as an acute or chronic lacunar inflammation, with 
the typical exudate at the mouths of the lacunae or crypts; or it may be 
manifested in the form of a parenchymatous inflammation, in which the 
whole substance of the tonsil is involved. There is no profound mystery 
surrounding the tonsil inflammations other than those of a biochemical 
nature, which are common to all inflammatory processes. The fact of 
chief importance is that in all types of tonsil inflammation there is a 
lesion of the epithelium lining the crypts, and that some form of patho- 
genic bacteria has penetrated it. The determination of the type and 
virulence of the microorganisms is of even greater importance than the 
determination of the type of tonsillar inflammation under the older 
classification. The bacteriological findings at least afford some useful 
information as to the virulence of the infecting microorganism, and, there- 
fore, influence the mode of treatment to a certain extent. If the virulence 
is marked, surgical procedure is contraindicated; indeed, the presence of 
an acute inflammation would of itself constitute a contraindication to 
operative interference. 

Much remains to be learned concerning tonsil inflammations. It 
may still be questioned whether it is good practice to remove tonsils 
in the wholesale manner now in vogue. The function of the tonsil in 
a child and in an adult is still an open question. When does the 
function cease or become so altered by disease as to justify the removal 
of the tonsil? Should the tonsil be ])artiany or completely removed? 
When removed, what organ performs its functions? These and other 
cjuestions are not fully answered. We know from clinical experience 
that when a tonsil shows a tendency to become the seat of recurrent 
inflammations the patient's health and life are conserved by its entire 
removal. Are there other methods of treatment tliat will better conserve 
the health and life of the patient? It is doubtful, though this is still an 
open question. The i-emoval of the debris fi'om the crypts, from time 
to tiin(\ would no doubt avert many acute exacerbations; the topical 



ACUTE LACUNAR TONSILLITIS 377 

application of solutions of silver might also prevent acute manifestations, 
but in the long run such methods of procedure must fail. The com- 
plete removal of the tonsil during a quiescent period must always succeed 
in preventing inflammations of the tonsil for all time to come. Will a 
tonsil thus removed recur? Never, if it is completely removed. Can it 
be removed by dissection with its capsule intact? Yes; with the most 
happy results. 

ACUTE LACUNAR TONSILLITIS. 



Synonyms. — Acute follicular tonsillitis; infectious tonsillitis; cryptic 
tonsillitis. 

Etiology. — The chief causes of this and other forms of tonsillitis are 
the local impairment of the epithelial lining of the crypts and the invasion 
of certain pathogenic bacteria, as has been pointed out in the Tonsils as 
Portals of Infection, and the Clinical Anatomy of the Tonsil. There are 
other factors which enter into the etiology, and they will be discussed in 
the following analysis : 

The Local Lesion of the Tonsil. — As shown by Goodale and Wright 
(p. 367), the crypts of the tonsil are the seat of absorption for dust and 
microorganisms, whereas the surface epithelium of the tonsil has but 
little part in this process. They have shown that dust, as carmine 
powder, is readily absorbed through the healthy epithelium of the crypts, 
whereas bacteria are not. Bacteria are only absorbed through dead or 
impaired cryptic epithelium. Hence, the prime requisite for tonsillar 
infection is an impairment of the cryptic epithelial lining. This condi- 
tion may be brought about by the retention of exfoliated epithelium 
and other debris in the crypts of the tonsil. The retention is formed by 
the constriction of the mouths of crypts from previous inflammation, 
and by the plica supratonsillaris and the plica triangularis which cover 
the moutlis of some of the crypts in such a manner as to prevent the 
expulsion of their contents. The toxin thrown out by the imprisoned 
microorganisms causes the death of the cryptic epithelium and thus opens 
the way for the invasion of the microorganisms into the tonsil and the 
general lymphatic and circulatory system, hence the constitutional symp- 
toms in this disease. 

The Bacteriology. — ^The bacteriology of acute tonsillitis embraces 
several pathogenic microorganisms, chief of which is Streptococcus 
pyogenes. 

Besides these, the Staphylococcus aureus and albus, the pneumococcus, 
and the leptothrix are sometimes present. 

Age. — The disease is more common in young adults between the 
twentieth and thirtieth years of life. It is also conunon in children, and 
more rare after the fortieth year of life. 

Catching Cold. — Tonsillitis is frequendy the immediate result of 
catching cold, which is but another way of saying the resistance was 
lowered, llms favoring the growth of the |)ntli()genic bacteria. 



37S '^V//-; PlfAHVXX AXD FAUCES 

Surgical Trauma. — Tlw iiiHanimations following sui-t>ical proceclures 
in the nose and epipliarvnx freciuently extend to the tonsil, and are of 
bacterial oriijiii. 

Specific Fevers. — Tonsillitis is often associated with the specific 
fevers, as scarlatina and diphtheria, and is of bacterial origin. 

Pathology. — In acute lacunar tonsillitis the tonsil is swollen, though the 
chief changes occur in the crvpts, where there is an accunudation of 
leukocytes and dead epithelial cells intermixed with pathogenic bacteria. 
The transudation of leukocytes occurs chiefly through the cryptic 
membrane rather than through the surface mucosa. The accumulated 
material in the crypts or lacimjie is sometimes entangled in a fibrous 
exudate or pseudoinenibrane, though the pseu(lomem})rane is not always 
])resent. 

Symptoms. — The Subjective Symptoms. — In this, as in other acute 
infectious piocesses, the onset is sudden and is attended by malaise and 
fever. Chilly sensations or light rigors may mark the attack. The 
temperature gradually rises until the end of the first to the third day to 
102° to 103°, and in young children it may rise as high as 104° to 105°. 
The febrile movement is accompanied by soreness upon swallowing, 
which as the disease progresses may become quite painful. The inflam- 
mation extends to the phar^^^geal mucous meml>rane, and even, in 
exceptional cases, to the Eustachian tube and the middle ear. 
There may be pain in the ear through reflex sources without actual 
inflammation in the tympanum. Tinnitus may also be present. The 
gland imder the angle of the jaw is usually swollen and tender, as it is in a 
state of great physiological activity in its attempt to check the invading 
host of bacteria which has passed through the impaired epithelial barrier 
in the crypts of the tonsil. The swollen condition of the tonsil and sur- 
rounding muscles renders rotary motions of the head somewhat painful, 
'^riie same conditions also render articidation and phonation imperfect, 
the voice being thick and indistinct. The tongue is coated with a 
yellowish-brown fur, and the breath is fetid and ofl'ensive. Transient 
albuminuria is sometimes present, especially if the attack is severe and 
))rolonged. Casts may also be found in the urine. Such a condition is 
connnon to all acute infectious processes in any part of the body, and do 
not necessarily point to grave results. 

The acute symptoms rarely extend beyond the third, fourth, or the 
fifth day. The febrile movement and the swelling and soreness rapidly 
sul)side until the temperatvu'e is normal and the act of deglutition and 
the rotation of the head may be performed with comfort to the patient. 
The patient, though convalescent, is often left in a very weakened condi- 
tion. 

The Objective Symptoms. — At the onset the tonsils are swollen and red, 
while the cry])ts may not present the characteristic yellowish furred appear- 
ance, especially in their central and posterior aspects. The pharyngeal 
nnicosa and the pillars of the fauces are usually redder than normal. At a 
later ])eriod the tonsil and phar^mx are still more swollen, and a creamy 
discharge is seen extruding from the mouths of one or more of the crypts. 



PLATE VII 




Acute Lacunar Tonsillitis. 

Tliis disease may usually be cured by one application of a 90 per cent, 
solution of the nitrate of silver. 



ACUTE LACUNAR TONSILLITIS 379 

The patches are not usually true membranous products, as found in 
pseudomembranous and diphtheritic inflammations, but are the secre- 
tions and debris which completely fill the crypts and are extruding from 
their mouths (Plate VII) . 

Occasionally there is a fibrinous exudate admixed with (he debris, 
which gives it some of the characteristics of an inflammatory membrane. 
The protruding secretion and debris are easily wiped away, in contra- 
distinction to the diphtheritic membrane, which is closely adherent to 
the epithelium. 

I have seen cases of diphtheria which closely resembled acute follicular 
tonsillitis, inasmuch as the membrane was loosely attached, on account 
of the solvent action of antitoxin administered eighteen to twenty-four 
hours previously. The debris is occasionally found upon the surface 
of the tonsil, upon the pillars of the fauces, and upon the posterior wall 
of the pharynx. It is easily removed with a cotton-wound applicator. 

Pharyngeal and lingual tonsils are usually simultaneously inflamed 
with the tonsil, and the yellowish exudate or debris peculiar to the faucial 
tonsil is found in the shallow crypts of the pharyngeal tonsil and still 
more shallow depressions of the lingual tonsil. The debris is similar in 
composition to that found in the crypts of the faucial tonsils. If the febrile 
symptoms continue after the faucial tonsil appears to be well, the pharyn- 
geal and lingual tonsil should be examined with a laryngeal mirror for 
evidences of inflammatory processes. 

Complications and Sequelae. — Complications and sequelae are com- 
paratively rare, the case usually ending favorably in seven or eight days. 
Under appropriate treatment the duration of the disease is often much 
shorter than this; one application of a strong aqueous solution of silver 
nitrate often ending the disease within a few hours. Occasionally, when 
only one tonsil is diseased, the other is attacked at the close of the first 
attack. When this is the case the febrile and other symptoms are 
repeated. The follicular inflammation is rarely followed by a phleg- 
monous inflammation of the tonsil or of the peritonsillar tissue (quinsy). 
The cervical glands, beginning with the one under the angle of the jaw, 
may suppurate. Purulent otitis media, pericarditis, pleuritis, erythema 
nodosum, and erythema multiforme have been reported as sequelae 
of acute tonsillitis. Transient albuminuria is a rather common com- 
plication. 

Diagnosis. — The following table will aid in the differential diagnosis 
between acute lacunar tonsillitis and diphtheria, although there are cases 
in which the differential points are obscin-e and dependence must be 
placed upon the bacteriological findings: 



380 THE PHARYXX AXD FAUCES 

Acute Lacunar Tnnf<illitis. Diphtheria. 

1. Onset marked l)y a sharp rise of 1. Onset, rise more gradual, 
temperature. 

2. Kapid, bounding pulse. 2. Slow, feeble pulse. 

3. Depression not marked. 3. Depression marked. 

4. Exudation limited to the tonsil, 4. Exudation extends beyond the 
especially the mouths of the crypts. tonsils and is not limited to the crypts. 

5. Exudate not adherent. 5. Exudate closely adherent. 

6. Exudate soft and friable. 6. Exudate firm and leathery. 

7. Exudate not distinctly mem- 7. Exudate membranous and may 
branous l)e removed in strips. 

8. Swollen glands uncommon except 8. Swollen glands common even in 
in severe cases. mild cases. 

9. Albuminuria not common. 9. Albuminuria common. 

10. Klebs-Loeffler liacillus absent. 10. Klebs-Loeffler bacillus present. 

I have seen cases in which repeated examinations failed to show the 
Klebs-Loeffler bacillus, which were finally sho\\ii at subsequent examina- 
tions. Absolute dependence must not, therefore, be placed upon nega- 
tive microscopic findings ; if, however, the Klebs-Loeffler bacillus is found, 
the case should be pronounced diphtheria, even though the clinical 
phenomena do not corroborate the microscopic findings. 

Treatment. — ^This type of tonsillitis is more amenable to treatment 
than any other. One application of a 50 to 90 per cent, solution of 
nitrate of silver, if applied locally during the first twenty-four hours of the 
disease, will in nearly every instance abort the attack. I have repeatedly 
used silver in this way, and upon the following day have almost always 
seen the disease under complete control. A second application is rarely 
required. The febrile and other symptoms rapidly decline and convales- 
cence is quickly established. This may appear to be an overstatement 
of the facts, but in my experience it corresponds with the facts. I have 
tried other remedies, but none of them have equalled the nitrate of silver. 
This strength of silver may appear to be caustic in action and unsuited 
for the treatment of acute tonsillar inflammation. As a matter of fact, 
it imites with the mucine so readily that its caustic action is greatly 
diminished before it acts upon the mucous membrane. It coagulates 
the secretions and blanches the mucous membrane, thereby checking 
the inflammatory infiltration of the tissues. It also entangles the patho- 
genic bacteria in the albuminate of silver and prevents further activity on 
their part. It appeals to me as an ideal remedy in the early stage of 
the disease, and is worthy of extended trial. 

In applying silver to the tonsil the excess of fluid should be squeezed 
from the cotton-wound applicator to prevent it trickling to the larynx, 
where it will produce violent spasm of the intrinsic muscles of the lar^aix. 
The silver salts are not well tolerated by the motor nerves and 
muscles of the larynx, and severe suffocative symptoms may be pro- 
duced by inattention to the technique of its application. I have seen 
cases in which cyanosis was pronounced from this cause. A little 
attention on the part of the physician will obviate this distressing occur- 



CHRONIC LACUNAR TONSILLITIS 381 

rence. Giiaiacol in a 25 to 50 per cent, solution of olive oil is the next 
most effective remedy. It should be applied locally two or three times 
daily for two days. The effect is pronounced, though not so immediate 
as with the nitrate of silver. It produces a hot, peppery sensation for 
about thirty seconds, followed by a sense of relief. 

The carbonate of guaiacol given internally in 5 grain doses every 
three hours exerts a decided beneficial action upon the course of the 
disease. 

The tincture of the chloride of iron in eight parts of glycerin given in 
teaspoonful doses every two hours is another good remedy. 

The salicylate of sodium, the benzoate of sodium, and the chlorate of 
potash are also recommended, but the silver solution is so much superior 
to either of the other remedies mentioned that it should be used in nearly 
all cases to the exclusion of the other remedies. 

If there is a history of repeated attacks of acute lacunar tonsillitis, 
the tonsils should be removed by complete dissection during the interval 
between the attacks. This procedure alone offers a considerable hope 
of permanent relief from the attacks and their more serious complications 
and sequelae, 

CHRONIC LACUNAR TONSILLITIS. 

Definition. — Chronic lacunar tonsillitis is characterized by the pres- 
ence of caseous material composed of layers of desquamated epithelial 
cells enclosing cholesterin crystals, fatty matter, leukocytes, micro- 
organisms, and occasionally calcareous deposits. The masses vary in 
size from a grain of wheat to a small bean. The crypts most often 
involved are those opening into the supratonsillar fossa and those 
covered by the plica triangularis, for the reasons already given in the 
Clinical Anatomy of the Tonsil. The tonsil may or may not be hyper- 
trophied, though it is generally in that condition. 

Etiology. — One of the chief causes of the disease is the retention of 
the desquamated epithelium, bacteria, and debris in the crypts, which 
in turn is due in part to the anatomical barriers afforded by the plicae 
supratonsillaris and triangularis. Back of all this there is probably a 
diseased condition of the epithelium lining the crypts, due to previous 
acute inflammations. 

Symptoms. — The subjective symptoms are not usually pronounced in 
character. The patient may complain of pain upon swallowing saliva, 
but not upon swallowing solid food (Ball). Neuralgic pains sometimes 
shoot toward the ear. Some patients have the sensation, lasting perhaps 
for onh' a minute or two, of a foreign body lodged in the tonsil. 

The objective symptoms are more pronounced and characteristic 
than the subjective ones. The patient coughs up the caseous masses, 
which have a fetid odor, and he consults a physician, who upon examina- 
tion notes the fetid breath and the yellowish masses in the crypts of the 
tonsil. Upon exerting pressure upon the tonsil with a flat instrument 
the caseous masses are forced from the crypts. If they are full to over- 



,3,S2 '/'///•; PHAinxx AXD fauces 

fiowiii"', the yt'llowisli sj)ot.s appear at the mouths mueh as they do in 
the acute form of the disease. 

The tonsils are usually enlarged, the size of the tonsils often being 
greater than appears upon superficial examination, as they are covered 
by the plica triangularis and plica supratonsillaris indeed, some of the 
largest tonsils I have ever removed were thus concealed from view. 
The plica triangularis is not an "adhesion" or inflammatory product, 
as some autliors state, but is an embryological structure, as stated in the 
section on the (^linical Anatomy of the Tonsil. When the anterior 
and median surfaces of the tonsil are completely covered by an imusually 
large plica triangularis, the mouths of the crypts cannot be seen without 
a throat mirror, or putting the patient "on the gag." By resorting to 
the latter of these expedients the tonsil is rotated forward so that its 
median surface may be seen by direct inspection. A blunt tonsil hook 
introduced into the crypts or into the pocket formed by the union 
of the plica triangularis with the tonsil will remove the caseous 
plugs and develop the fetid odor to its full extent. The caseous masses 
are not adherent, but are easily removed with a blunt hook, or by 
pressure upon the surface of the tonsil. 

Occasionally the mouth of a crypt becomes closed by inflammatory 
adhesions and the caseous mass thus encysted, the yellowish color 
showing through the thin membranous covering over the mouth of the 
crypt. 

A tonsil thus affected is subject to exacerbations of acute symptoms, 
generally of a mUd type, the mucous membrane becoming slightly 
reddened. There is also some soreness upon swallowing. The tempera- 
ture is but little elevated and attracts no attention. The patient some- 
times complains of slight huskiness of the voice, and has fits of coughing 
from the local irritation in the tonsil. During these attacks he often 
coughs up the caseous masses. The repeated removal of the plugs 
affords some relief, and their tendency to reform is diminished, though 
a cure by this procedure does not often occur (Fig. 266). 

Treatment. — If the symptoms are annoying to the patient, and recur 
at frecjuent intervals, or if the patient has had rheumatism, enlarged 
glands in the neck, or has other evidences of infection in a remote part 
of the body, which may reasonably be assigned to absorption through 
the tonsils, they should be removed in their entirety. 

Slitting the crypt walls, followed by the application of a 20 per cent, 
solution of trichloracetic acid or of strong solution of iodine, has been 
strongly advocated by Kauffmann and others. Personally, I do not 
recommend this mode of treatment, as it is, at the best, a makeshift and 
fails to meet the fundamental requirements of the condition. The tonsil 
crypts are diseased, chronically infected, and have a tendency to continue 
in a diseased state. 'J'he rational ])rocedure is, therefore, to completely 
remove the tonsil, preferably with its capsule intact. (For a description 
of the operation, see Surgery of the Tonsils.) 



PHLEGMONOUS TONSILLITIS AND PERITONSILLITIS 383 



CALCULUS OF THE TONSIL. 

Small quantities of calcareous or gritty particles are often found in the 
centre of the caseous plugs filling the crypts of the tonsil in chronic 
lacunar tonsillitis. They sometimes become quite large and fill the 
crypts, and are known as calculi of the tonsil. The etiology is not clear 
beyond the fact that they are usually found in tonsils affected by chronic 
inflammation. 

Symptoms. — The symptoms are identical with chronic lacunar 
tonsillitis with caseous plugs in the crypts. That is, there are recurrent 
attacks of mild tonsillitis with redness especially marked around the 
affected crypts. 

Treatment. — The treatment consists in the removal of the calculus, or 
the removal of the tonsil as in chronic lacunar tonsillitis. If the calculus 
is not easily disengaged from the crypt, an incision of the wall of the 
crypt facilitates its removal. Pain may be obviated by injecting a 4 per 
cent, solution of cocaine into the substance of the tonsil in the region of 
the calculus. 



PHLEGMONOUS TONSILLITIS AND PERITONSILLITIS (QUINSY). 

Phlegmonous tonsillitis is an acute abscess within the substance 
of the tonsil, whereas peritonsillitis is an acute abscess in the peritonsillar 
tissue. The processes are the same, while the location of the purulent 
accumulation is different. Peritonsillar abscess, or peritonsillitis (quinsy), 
is much more common than phlegmonous tonsillitis. 

Etiology. — The causation is about the same as given under acute 
lacunar tonsillitis. Peritonsillitis (quinsy) probably arises from an 
infection of the crypts in the supratonsillar fossa, which are large, slit- 
like cavities with irregular outlines, and which are in intimate relation- 
ship with the posterior and outer aspect of the tonsil. These crypts 
appear to be the usual route of peritonsillar infection, hence the abscess 
is usually located in the tissue external to the tonsil. The disease is 
common in young adults and rare in children. 

Symptoms. — Phlegmonous tonsillitis is more rare and less severe 
tiian peritonsillitis. Otherwise the symptoms are much the same. 
The onset is gradual in so far as the peritonsillitis is concerned, though 
there may have been a preceding acute lacunar tonsillitis with its sudden 
onset and severe symptoms. The temperature rarely exceeds 99° or 100°, 
whereas in acute tonsillitis it often rises to 103°. 

The pain progressively increases with the extension of the purulent 
accumulation until it is almost unbearable. The muscles of mastication 
are encroached upon by the abscess so that the patient has the greatest 
difficulty in ()])eniiig the mouth sufficienUy wide to ])ermit of an examina- 
tion of the llii'oiit. Swallowing becomes difficult and very painful. The 
disease is usually limited (o one side. The saliva dribbles from the 



;-!X4 'I'll I' I'lIMiVSX AM) FAUCES 

iiiouth and forms one of the characteristic syni[)t()nis. Lateral move- 
ment of the head pnxhices pain on account of the infiltration of the tissues 
of the neck in the region of the tonsih 

Thick viscid secretion forms in the throat, and it is with the greatest 
(HfHculty that the patient succeeds in removing it. The tongue is 
heavily coated and the breath fetid. Breathing is interfered with on 
account of the swollen mucous and submucous tissue of the pharynx. 
The ])atient has an anxious expression of countenance. During sleep 
he often has suffocative attacks which awaken him. Laryngeal dyspnea 
from extension of the edema to the lar^nigeal tissue is fortunately rare. 

Objective Symptoms. — At the onset there is slight redness and swelling 
uj)()n one side. Both tonsils are rarely affected at the same time. If 
both are affected, the second usually begins as the first subsides. If both 
are affected at once, the suffocative symptoms are more pronounced and 
alarming. As the disease progresses the redness, tenderness, pain, and 
swelling increase in severity. If the abscess is in the tonsil, it is pushed 
toward the median line or even beyond it. If the abscess is in the 
peritonsillar tissue, the swelling often appears to be in the region of the 
upper portion of the anterior pillar. As a matter of fact, the apparent 
swelling in this region is often the anterior border of the tonsil projected 
against the pillar by the pus behind the tonsil. Incisions in this region 
often fail to reach the pus cavity for this reason; that is, the incision is 
carried directly into the tonsil instead of into the pus cavity outside 
of the tonsil. If the depth of the incision is carried beyond the outer 
border of the tonsil, the pus will be more often found. It should be 
remembered that the anterior third of the tonsil projects forward beneath 
the anterior pillar; hence, in making an incision through the anterior pillar 
to evacuate the pus, it should be made far enough anteriorly to escape the 
anterior border of the tonsil, and should be directed in an outward and 
a backward direction, so as to go outside of the capsule of the tonsil. If 
these anatomical facts are borne in mind, the anterior incision will nearly 
always evacuate the pus. If a posterior incision is to be made, it should 
be directed outward through the posterior pillar, or in its immediate 
vicinity, as the pus pocket often extends posteriorly to the tonsil. 

The soft palate and uvula, as well as the pharyngeal mucous mem- 
brane, are red and edematous. The region of the tonsil is of a deep, 
dusky red color. The crypts are often filled with a pulp-like debris, 
whicli is probably the original source of infection. The infection does 
not originate in the peritonsillar tissue, but in the supratonsillar crypts 
of the tonsil. 

Digital examination of the tonsillar region shows more or less distinct 
fluctuation. The focal centre of fluctuation is about one-quarter of an 
inch external to the free l)order of the anterior })illar; at the jimction of 
the upper third with the middle third of the tonsil; or it may be posterior 
to the tonsil. 

The duration of the disease em])races from five to fourteen days when 
allowed to run its course, though it may extend over a longer period. 
The termination of the disease is marked by the spontaneous or artificial 



PHLEGMONOUS TONSILLITIS AND PERITONSILLITIS 385 

discharge of fetid pus. When the discharge is spontaneous it usually 
takes place through the anterior pillar, though it occasionally occurs 
through one of the crypts. 

Complications and Sequelae. — Complications and sequelae are rare. 
Cases are on record, however, in wh"ch the following conditions were 
present : 

(a) Edema of the glottis from the downward extension of the process. 

(6) Strangulation of an adult from the spontaneous rupture of the 
abscess sac. 

(c) Ulceration thrombophlebitis of one of the large veins of the neck. 

(d) Ulceration of one of the large arteries in the submaxillary region. 

(e) Chronic peritonsillitis with an intermittent flow of pus (Ball). 
(/) Encysted abscess in the tonsil. 

Treatment. — The Onset. — If the case is seen early when there is an 
infiltration and redness of the mucous membrane and the deeper tissues, 
but no pus, cold applied in the mouth or externally at the angle of the 
jaw diminishes the pain, and, indeed, it may abort the attack. Cold 
may be applied internally by means of iced gargles or by sucking 
cracked ice. It is applied externally with a Leiter coil. It should be 
borne in mind that cold applications are indicated in the early stage 
of acute inflammation, whereas hot applications are indicated in the 
more chronic stages. In very acute inflammation proliferation and local 
leukocytosis are active, whereas in the later stages cell proliferation 
and local leukocytosis are lessened, though the proliferated cells remain 
permanently; hence, heat is indicated to increase the leukocytosis, as the 
lymphocytes are needed to clear up the inflammatory products and the 
polynuclear leukocytes to destroy the bacteria. 

Pain may be relieved by the inhalation of hot vapors or steam, or by 
the application of hot poultices or a hot Leiter coil to the neck and 
angle of the jaw. Local applications of cocaine may also be used for the 
same purpose. The leukodescent 500 candle-power lamp (Fig. 19), when 
available, provides an excellent mode of treatment. In peritonsillitis 
the rays of the lamp should be applied over the neck and angle of the 
jaw upon the affected side. The lamp should first be passed over the 
neck a few times at a distance of six inches, and then more slowly for 
ten to thirty minutes at a distance of eighteen inches. Such treatments 
will relieve the pain and reduce the swelling more readily and certainly 
than cold applications, as they promote the reaction of inflammation. 

Surgical Treatment. — When the process is well established the evacua- 
tion of the pus is imperatively indicated. The point of election for the 
incision (in quinsy) should be determined by the location of the pouch- 
ing or fluctuation. It is usually in front of the anterior pillar on a level 
with the junction of the upper and middle thirds of the tonsil, though it 
may be in the posterior ])illar or through the tonsil. Some recent writers 
have advocated the posterior pillar as the most favorable site for the 
incision, whereas most of the earlier authors recommend the anterior 
pillar. As a matter of fact, many of the failures to evacuate the pus 
through the anterior incision are due to a failure to take into account 
25 



3S() 



rilK I'IfAh'YXX AXD FAUCES 



t\\v fact tliat the tonsil often extends forwanl beneath the anterior pillar. 
The incision as usually made, therefore, penetrates the tonsil instead of 

the tissue outside of it (Fig. 23()). 



HYPERTROPHY OF THE TONSIL. 



This sulrect is nearly akin to chronic lacunar tonsillitis, as in that 
disease the tonsil is nearly always hypertrophied. Likewise the hyper- 
trophic tonsil is nearly always the subject to chronic lacunar inflammation. 
Nevertheless, it is practical to consider hypertrophy of the tonsil as a 
separate entity, as there are certain general considerations which justify it. 
Hypertro])hy of the tonsil usually begins about the second year of 
life and continues until young adulthood. Instances have been noted in 

which the babe seemed to have 
I'lo. 230 been born with enlarged tonsils. 

It is therefore occasionally con- 
genital. ^Yhile the hypertrophic 
process may continue into young- 
adult life, it generally ceases to 
actively develop after puberty, 
and often seems to undergo an 
atrophic change. As a matter 
of fact, the apparent atrophy is a 
sclerosis; that is, the connective- 
tissue element develops in ex- 
cess of other structures and the 
tonsil becomes firmer and firmer 
and shrinks on account of the 
contraction of the connective 
tissue formation. The differ- 
ence between a child's tonsil 
and an adult's tonsil is thus ex- 
plained: In a child the enlarge- 
ment is due to an increase in all 
the celhdar structures composing the tonsil, whereas in an adult the 
connective-tissue cells are increased in excess of the other cellular elements 
(hyperplasia). In a child the tonsil is soft and smooth in outline, whereas 
in an adult it is often much harder and nodular in outline. In some 
children the hypertrophied tonsil is so loosely attached to the sinus 
tonsillaris that it can be easily removed in its entirety, with its capsule 
intact, with the tonsillotome. In others it is more firmly attached, and 
the tonsillotome only removes the superficial portion. In a few adults 
the tonsil is loosely attached, though it is ordinarily more firmly attached 
than in children. The exact size of the tonsil is not always shown 
by the ordinary examination, as only a superficial portion (median) is 
visible. The greater portion of the tonsil may be hidden beneath the 
anterior ])illar, the plica triangularis and the ])lica su])ratonsillaris. 




The author's dissection back of the capsule of 
the tonsil to evacuate a peritonsillar abscess. The 
dissection is started as though the tonsil were to 
bs removed. 



HYPERKERATOSIS OF THE TONSIL 387 

Wilson has shown by the examination of a number of cadavers that 
the average height of the tonsil above the margo supratonsillaris is about 
^ inch. Hence, too, much importance should not be attached to the 
apparent size of the tonsil. It should be palpated with the index finger 
through the mouth, and its boundaries defined and its movability (degree 
of attachment) determined. In this way a good idea of the degree of 
enlargement and the ease with which it may be removed may be 
estimated. 

The so-called submerged tonsil (Pynchon) is one that has undergone 
fibroid changes and is hidden behind the anterior pillar and the plica 
triangularis. Pynchon speaks of the plica triangularis as "an hypertrophy 
of the free border of the anterior pillar," whereas it is a normal structure 
appearing in embryonal life, and in some of the lower animals develops 
into the tonsil itself. There is no muscular tissue in the plica triangularis, 
and it should be removed w^ith the tonsil. When it is left in place it may 
form a pocket or pouch where food and other debris collects, and is the 
source of considerable local irritation. 

The hypertrophic and hyperplastic tonsil may have healthy crypts, 
but, as a rule, the reverse is true. The lining epithelium of some of the 
crypts is usually of low vitality or entirely deadened or hornified, and 
is unable to resist the invasion of pathogenic microorganisms. During 
the transitional stage between hypertrophy and hyperplasia of the tonsil 
hyperkeratosis of the cryptic epithelium may take place (hyperkeratosis 
of the tonsil). The leptothrix (mycosis tonsillaris) is an adventitious 
complication and not a disease per se (G. B. Wood). The hyperkeratosis 
is a self-limited condition, and usually disappears spontaneously in from 
one to three years. 

If an hypertrophied or hyperplastic tonsil gives rise to untoward 
local symptoms or to constitutional disturbances, or to local morbid 
lesions in remote portions of the body, it should be removed in its entirety. 
(The Tonsils as Portals of Infection.) 

Treatment. — Palliative treatment directed toward the removal of 
the caseous plugs from the crypts, and from the pocket formed by the 
union of the plica triangularis with the tonsil, may be instituted when 
for any reason an operation cannot be performed. The incision of the 
cryptic walls and the application of acids or iodine, as advocated by 
Kauffmann, Ball, and others, may also be tried, but the best results are 
obtained by the complete removal of the tonsil with its capsule intact. 
(Operations upon the Tonsils). 



HYPERKERATOSIS OF THE TONSIL; MYCOSIS LEPTOTHRICIA. 

According to Dr. (Icorgc B. Wood, "Hyperkeratosis of the tonsillar 
tissues of the throat is a disease, or, better, a condition , characterized ])y 
the appearance of numerous white projections not only from the cryptal 
orifices of the tonsils proper, but also from the orifices of the lymph 
follicles on the |)osteri()r and lateral ])liai'yiigeal walls and on the lateral 



388 THE PHARYNX AND FAUCES 

^losso-cpi^lottidean folds. This condition does not occur on portions of 
the throat wliere there is no lymphoid tissue. The lymphoid tissue of the 
upper respiratory tract, however, is so ubiquitous that occasionally we 
may see the little white projections on almost any part of the mucosa. In 
the large majority of cases the condition is limited to the faucial and 
lingual tonsils. That it reaches its greatest development on the base 
of the tongue and at a position just behind the lateral glosso-epiglottidean 
folds and the posterior part of the inferior poles of the tonsils is due almost 
entirely to mechanical reasons. The contractions of the muscles during 
swallowing prevent food from coming in intimate contact with the 
surface of these parts, and therefore permit the projections to grow 
undisturbed. Although the horny material is quite resistant to trauma, 
the bacterial accumulations which form the greater mass of the projections 
are easily brushed off, so that the size of the growth is much greater 
wdiere it is protected from mechanical disturbances. 




Hyperkeratosis. Showing the typical appearance under low power. The horny mass is grow- 
ing from a comparatively small area of the cryptal epithelium, and the plug shows the ordinary 
fraying of its edges, a, crystal epithelium; b, horny material; c, masses of bacteria; d, follicles. 
(Wood.) 

"The symptoms caused by this condition of the throat are either entirely 
wanting or very slight, and are due for the greater part to the local 
irritation caused by the hard, horny plug. If they project from the base 
of the tongue so as to come in contact with the epiglottis, there is an 
irritating tickling sensation which causes a hacking cough. If they are 
so placed as to be compressed during the act of swallowing, they may 
give rise to a slight pricking pain. 

"Occasionally among the rich and various bacterial flora which grow 
in such luxuriance on this horny material there may lurk a germ pos- 
sessed of more or less pathogenic power, which may set up an accom- 
panying inflammatory reaction in the tonsil or surrounding structures. 



HYPERKERATOSIS OF THE TONSIL 389 

Hence, the relation which some observers have noticed between acute 
tonsilHtis and this disease." 

Dr. Wood also says that to understand correctly the pathology and 
also the etiology of lacunar hyperkeratosis we must turn our attention 
for a few moments to the anatomy of the normal active tonsil. The tonsil 
consists of four chief elements: the connective tissue, the germinating 
follicles, the interfollicular tissue, and the crypts. 

1. "The connective tissue, that is, the trabecule and the reticulum, 
acts as a supporting framework to the tonsil substance proper. The 
trabeculse carry bloodvessels, the nerves, and the lymphatics. 

2. "The germinating follicles are the centres wherein the larger mother 
cells of the leukocytic group undergo karyokinesis and form young 
lymphoid cells. 

Fig. 238 




Hyperkeratosis, fauoial tonsils. This specimen is"from a case whicli had been vigorously 
treated with antiseptics. There are practically no microorganisms. The black staining is due 
to nitrate of silver which has been used in treating the patient, a, intact cryptal epithelium; 
b, keratoid plug. (Wood.) 

3. "The interfollicular tissue is made up of lymphoid cells in various 
stages of development. The cells making up this interfollicular tissue 
differ in size and shape according to their location. They are greater in 
number around the follicles, and show greater difference in their ana- 
tomical construction in the immediate neighborhood of the crypts. 

4. "The crypt of the tonsil is its peculiar and most characteristic struc- 
ture. It consists of an invagination of the epithelium from the surface 
of tlie tonsil, which has undergone a very interesting anatomical change. 
Tn the first place the subepithelial connective tissue which is present in a 
marked degree beneath the surface epithelium disappears as soon as the 
epitiielium starts to form the crypts. This permits the epithelial cells 
to come in direct contact with the lympliatic structures of the tonsil, 



390 



Till-: PHAUYXX AS!) FAUCES 



and verv treciueiitly it is inij)().s.sil)lc' to distinguish a dividing line between 
the epithehuni of tlie vv\\)i and the interfolhcular tissue. The epithehum 
of the crypt, unHke its progenitor wliich covers the surface of tlie tonsil, 
does not form a compact unbroken barrier or protection. For the greater 
part of its extent it presents an intact line only one or two or possibly three 
cells in thickness. Toward the parenchyma the epithelial cells show a 
peculiar condition. They are separated from each other by interposed 
cells varying in type from slightly changed epithelial cells to a well- 
formed lymphocyte. The epithelial cells may also extentl from the 
(•ry])t into the tonsillar substance, suggesting the ramifications of a 
malignant epithelioma. The smaller terminal invaginations of the 
cry{)tal epithelium are usually solid sprouts, frequently with central 
keratosed cores. The lumen of the crypt is formed by the subsequent 
exfoliation of the keratosed cells. 




Hyperkeratosis. Cross-section of a crypt filled with keratoid material and bactf 
eiiithelium; b, hornified cells; c, Ijmphoid tissue. (Wood.) 



"Turning now to hyperkeratosis, we find the epithelium of the crypts 
showing characteristic changes. In hyperkeratosis the epithelium loses 
its rarefied condition and becomes ordinary pavement squamous epithe- 
lium similar to that covering the surfaces of the tonsil, except that 
generally it does not show the connective-tissue papillae. The crypt of 
the tonsil is markedly dilated and filled with a horny mass, which merges 
at various points into the epithelium, though in sections stained with eosin 
and thionin there seems to be a more or less distinct line where the epithe- 
lial cells become keratosed. The living cell has a nucleus which stains 
with thionin, and its protoplasm is of a purplish color, due to the mixed 
staining with eosin and thionin. The keratosed material stains only 
with eosin, and is, therefore, of a bright pink color. (Occasionally in the 
keratoid mass a verv faintly stained nucleus is found, indicating that the 



HYPERKERATOSIS OF THE TONSIL 



391 



material of which the mass consists has been originally derived from 
epithelial cells. 

"Accordmg to the mechanical circumstances by which the tonsil 
is surrounded, the horny mass becomes sooner or later broken up into 
layers, between which multiply and grow organisms of all varieties. This 
fraying of the cryptal plug may take place within the crypt itself, so that 
the resulting fissures permit the bacteria at times to penetrate almost 
but not quite to the living epithelium. My to tic figures may be seen 
in the epithelium at different places, but especially along the border to- 
ward the parenchyma of the tonsil. The epithelium is, therefore, in a 
state of active growth. This eccentric growth, however, w^iich results 
in the formation of the keratoid plug, is not equally distributed to all 
parts of the epithelial lining of the tonsillar crypts. Take, for instance, 



^ 







Hyperkeratosis. Cniss-s-rtiiiu ol nie lernunal iioiuoii ot a ciypt showing the concentric 
arrangement of ths layers of horny material and the epithelium, which is still somewhat disin- 
tegrated, n, epithelium; b, horny material in ciypts; c, lymphoid tissue. (Wood.) 

a single individual crypt: a portion of the epithelium may still persist in 
its normal condition of partial disintegration without a discernible border 
line between it and the tonsil parenchyma; in another part the epithelium 
may exist simply as a barrier of cells with a very thin layer of sub- 
epithelial connective tissue, and again in the same crypt we may see the 
hyperkeratosis in its most beautifid and characteristic appearance. 

"This change in the epithelium of the crypts is the characteristic 
pathological feature of hy])erkeratosis. Besides this there are generally 
other changes in the tonsil. Tlie connective tissue extends from the 
surface epithelium for some (nstauce down along the crypt. The 
follicles are small and much less uunici'ous, and tiic suiToiUKhiig zone 
of lyui])hofyt(s lias become (■()ui])arati\ (>ly iusiguificaiif. The inilolic 



392 THE PHARYXX AXD FAUCES 

figures in the follicles, though present, are less numerous, and the whole 
as])eet of the organ is one of suppressed activity. We sometimes find, 
however, signs of local irritation in the immediate neighborhood of 
the crypts, as evidenced by the outwandering of polymorphonuclear 
leukocytes from the capillaries and their penetration between the cells 
of the cryptal epitheliinn. This irritation is easy to understand when 
we consider that the crypts contain a large number of saprophytes and 
probably also pathogenic microorganisms growing actively and receiving 
their nutriment from the accumulated keratosed cells. 

"The toxins elaborated by these organisms must be absorbed to a 
greater or less extent V)y the tonsillar tissue. It is probably due to the 
fact that the cryptal epithelium has become an impact protective barrier 
that a more noticeable reaction is not a common result.'' 

Hyperkeratosis is a condition peculiar to young adults, and is self- 
limited, from two to three years being required for it to run its course. 
Treatment is unnecessary, though if the bony masses cause irritation 
they may be removed by cauterization. The electrocautery should be 
used to destroy the bany masses, and the tissues surrounding them 
should be penetrated until only healthy tissue remains. From three to 
four masses may be thus treated at sittings one week apart. 



CHAPTER XXIII. 

THE SURGERY OF THE TONSILS. 

It is being more and more recognized that the complete enucleation 
of the tonsil with its investing capsule is the most satisfactory method of 
dealing with diseased tonsils. It is true that in a certain number of cases 
the distressing symptoms yield to less radical measures, as the application 
of the cautery to the crypts, the incision of the crypts, the removal of 
the retained debris from the crypts, and the partial removal of the tonsil. 
I believe that if these cases were observed for a period of five or more years 
it would be found that the tonsil is still the seat of diseased processes not 
unlike those present before the operations above named. In addition 
to the diseased conditions it would also be found that in some instances 
the tonsil tissue had recurred, oftentimes in greater bulk than before 
the operation. 

If, on the other hand, the tonsil is removed in its entirety with its 
investing fibrous capsule, the diseased processes in the tonsillar fossa 
and the tonsillar tissue will never recur. F. E. Hopkins, in a review 
of the literature since 1856, found several recorded cases of recurrence, 
chiefly before the year 1870, though instances of recent date were also 
cited. His conclusion coincides with that of Sir Morrell Mackenzie, 
Sir Felix Semon, and the author, that recurrence is nearly always due 
to incomplete removal of the tonsil. D. Braden Kyle expresses the 
opinion that some cases of apparent recurrence after excision of the 
tonsil are, in reality, the regrowth of an adenoma, the tonsil having 
taken on that type of benign neoplastic development. N. L. Wilson 
says that the complete removal of the tonsil may be followed by an 
inflammatory process in the tonsillar fossa, but that such processes will 
not often be found after a period of two years subsequent to the operation. 
Tuberculous and specific taints no doubt account for some of the recur- 
rences after tonsillotomy. 

It seems to me, therefore, after considering all the data obtainable, 
including my own experience, that many of the conditions heretofore 
regarded as only calling for cauterization, incision, partial removal, etc., 
should be operated by the complete method, whereby the entire tonsil 
with its investing fibrous capsule is removed. 

In the following indications it should be remembered that they ai-e 
given with especial reference to the complete operation technically 
known as tonsillectomy: 

(a) Nasal catarrh and 

{!)) Ear diseases are sometimes true indications for tonsillectomy. 
Pynchon says: "In a goodly number of those cases applying for ti'cat- 



304 7V//-; PHARYXX AXD FAUCES 

iiient for nasal catanii, or for ear disease, in wliieli a plainly apparent 
hypertrophy of the faueial tonsils does not exist, it will be foinid upon 
close inspection that there is present a certain degree of faueial fulness 
which is markedly increased, by causing the patient to gag. Among the 
embellishments of this every -day picture an abnormal faueial redness 
is observed, gradually increasing in depth of color from the normal pale 
pink of the lowest point of the pharynx disclosed by the use of the tongue 
depressor. There will also be observed a tendency for frothy saliva 
to adhere to the parts." The relationship between nasal catarrh and 
tonsillar disease does not seem perfectly clear, while that existing between 
the tonsil and the ear is more apparent, as the palatophar\aigeus muscle 
extends to the pharyngeal orifice to the Eustachian tube, and inflamma- 
tions of the tonsils and pillars might readily extend along the pharyngo- 
palatine fold to the mucosa of the tube and thence to the middle ear. 
Repeated anginas in this region may result in degeneration of the palato- 
pharyngeal muscle fibers and thus impair the muscular mechanism that 
controls the patency of the tube. Again, infectious material in inflamma- 
tions of the tonsils may gain entrance to the tube and middle ear, either 
during coughing or vomiting, or in extensive inflammations by the 
destruction of the cilise of the epithelium lining of the tube. Ordinarily 
the cilife with their wave-like motion carry the secretions from the middle 
ear to the epipharynx. When they are destroyed, or their action is 
inhibited by violent inflammation, the entrance of foreign matter, as 
bacteria, etc., into the middle ear is comparatively easy. Hence, certain 
ear diseases having their origin in tonsillar inflammations call for the 
removal of the tonsils. 

(c) Recurrent attacks of tonsillitis independent of ear or pharyngeal 
complications usually justify the enucleation of the tonsils. The opera- 
tion should not, of course, be done during one of the acute manifestations, 
as to do so might give rise to severe infection of the wound and deeper 
structures. 

(d) By referring to Fig. 234 it will be seen that the tonsils drain into 
the deep glands of the neck. When these glands are enlarged and 
tender the tonsils are usually the source of the infection, and if there is a 
history of repeated glandular involvement the tonsils should be excised. 

(e) When the crypts of the tonsils are examined and they are found 
more or less filled with debris and bacteria, tonsillectomy should be 
considered. If the debris is removed with a tonsil hook or with a tonsil 
syringe (Fig. 266), the inflammation temporarily disappears, but in 
most instances it returns. If after repeated trials the inflammation 
recurs, tonsillectomy is indicated. 

(J) I^aryngitis with attacks of hoarseness is often due to tonsil disease, 
hence the tonsils should always be examined; and if the crypts are 
diseased or the tonsils are hypertrophied, the tonsils should be removed. 

((/) Hypertrophy of the tonsils is an evidence of a diseased process, 
for in a perfectly normal throat the tonsils are of small size. There is a 
divergence of opinion upon this point, some writers holding that the 
tonsil is an organ of the body, while others believe it to be a pathological 



TONSIL OPERATIONS 395 

entity which, under irritation from constant bacterial infection, becomes 
enlarged either through hypertrophy or hyperplasia. When thus changed 
its function as a lymphatic gland is impaired or lost, and the physical 
economy is best served by its complete ablation. 

(h) Chronic follicular tonsillitis is an indication for tonsillectomy, as 
there is little likelihood of curing it by simpler methods. Even if the 
crypt are closed by the use of the actual cautery, the low vitality of the 
tissue forms a favorable site for infection and inflammation. 

(i) Follicular pharyngitis is, according to George Troup Maxwell, 
often caused by a chronic suppurative follicular tonsillitis. He claims 
that after the tonsils are removed the follicular pharyngitis disappears. 

(i) Tuberculous infection often begins in the tonsils, and when such 
a process is demonstrated or strongly suspected, the tonsils should be 
enucleated, 

{k) Recurrent acute articular rheumatism following acute tonsillitis 
is an indication for tonsillectomy. 

TONSIL OPERATIONS. 

There are so many methods of operating upon the tonsils for the cure 
or relief of the morbid conditions affecting them and the neighboring 
structures and organs, that it is impracticable to attempt to describe 
all of them. I shall, therefore, select those methods which appeal to 
me as the most rational from a clinical and surgical standpoint, and 
which have, after long trial, given the best results. Some of the proce- 
dures to be described are not recommended as the best, but under some 
circumstances they must be resorted to as preliminary or tentative 
measures. Hemophilia, the reluc ance and refusal of the patient to 
submit to what seems to be the best method will occasionally lead the 
surgeon to elect an incomplete method of operating. Hence, both com- 
plete and incomplete operative procedures will be described, and their 
comparative merits stated as fairly as possible. 

Complete Tonsil Operations.— By the term "complete tonsil opera- 
tions," I mean those surgical procedures whereby the faucial tonsil is re- 
moved in its entirety with its capsule intact. Clinical observations have 
clearly shown that any procedure stopping short of this is often followed 
by little or no permanent improvement in the conditions for which it 
was done. Numerous cases are on record, and doubtless manyfold 
more are unrecorded, in which there was a continuation of the patho- 
logical processes and even of the recurrence of the tonsillar tissue after 
an incomplete operation. 

As has been stated in a preceding paragraph, even after the complete 
removal of the tonsil, the sinus tonsillaris is sometimes the seat of an 
inflammation, but that it rarely persists for more than two years. I can 
say from a personal experience covering about 1000 cases in which the 
tonsils were removed in their entirety with the investing capsule intact, 
that such subsequent inflammations have been exceedingly rai-c, wliile 
recurrence of the tonsillitr tissue lias never taken j^lace. 



396 THE PIIARYXX AXD FAUCES 

On the otluT hand, 1 can refer to a larger number of cases in which I 
did an incomplete operation, or what is knowii as "clipping the tonsils" 
with a INIathieii's tonsillotome or other instrument, in which the subse- 
quent tonsilhir inflannnations occurred comparatively frequently. 

It seems, therefore, that the time has come when a text-book should 
clearly recommend the complete operations upon the tonsils as the ones 
that should be used if it is at all expedient to do so, and that the incom- 
plete operations should be resorted to only when the peculiar conditions 
of the patient contraindicate either of the complete methods, or when 
other circumstances prevent their adoption. 

The Author's Complete Operation with Right -angle Knife and Ecraseur. 
— ^While every detail in the following technique is not original with me, the 
operation as a whole has been my owii creation, especially with reference 
to the removal of the entire tonsil wuth its capsule intact. In most 
cases the diseased tonsil is composed of three lobes, or masses, each with 
an investing capsule, the three lobes being held together by a fibrous 
envelope amovmting to a secondary enveloping capsule. For all prac- 
tical purposes the tonsil may be regarded as one mass with an investing 
capsule, and as such it may be removed in its entirety. 

(a) Anesthesia may be either local or general. Personally, I prefer 
local anesthesia, except in those cases in which, for various reasons, the 
patient cannot be operated in the conscious state. This is a matter that 
must be decided by each surgeon, as the personal element enters so 
largely into its consideration. 

Local anesthesia may be induced by swabbing the tonsils and the faucial 
arches at five minute intervals with an aqueous solution containing 
10 per cent, of cocaine and 5 per cent, of carbolic acid. Both ingredients 
produce blanching and anesthesia. From five to ten applications are 
usually required to produce complete anesthesia. In some cases a single 
application of a 20 per cent, solution of cocaine should be applied, A 
more frequent use of the 20 per cent, solution is quite liable to produce 
toxic results. 

Robert E. Moss called my attention to the hypodermic injection of 
4 per cent, cocaine in a 1 to 2000 solution of adrenalin (first published by 
Heitzmann) as a speedy and satisfactory method of inducing local 
anesthesia in the tonsillar region. I have used it with great satisfaction 
in a large number of cases. 

The solution is made by adding 4 per cent, of cocaine to a 1 to 2000 
solution of adrenalin. 

The solution should be injected into the tissues surrounding the tonsil 
rather than into the tonsil itself. For instance, it should be injected at 
the upper, middle, and lower portions of both anterior and posterior 
pillars respectively, and just above the supratonsillar space. About 
1 minim of the solution should be injected at each point. Street's 
syringe (Fig. 241) is well adapted to the purpose. 

Anesthesia is thus immediate and the operation may be performed at 
once. After the first tonsil is removed prepare the other in the same 
manner. 



TONSIL OPERATIONS 



397 



The adrenalin usually prevents severe hemorrhage during the opera- 
tion and lessens the cocaine toxemia. 

The position of the patient is a matter of some importance. Under 
local anesthesia the upright position in the operating chair should be 
used. Under general anesthesia the patient is placed upon the operating 
table, with his head either over the end of the table in the Rose position, 
or upon his side (Fig. 209), according to the preference of the surgeon. 
A mouth gag (Fig. 210) should be used if a general anesthetic is given. 



^^=^^ 




Street's tonsil hypodermic syringe. 

In the further description of the technique I will assume that the patient 
is conscious and in the upright position. 

(6) Seize the tonsil with the vulsellum forceps (Fig. 242), one prong 
tip being placed in the supratonsillar fossa, and the other at the base of 
the tonsil. When they are thus placed they should be pushed deep into 
the tissues, closed and locked. In this way they engage the fibrous 
capsule or deep surface of the tonsil, and will not tear loose except in 
young children when traction is made. 

When the blades are closed the bulk of the tonsil lies between the shanks 
of the instrument, as shown in Fig. 243. This has a distinct advantage 
over a superficial grasp of the tonsil, as it enables the surgeon to dissect 
around it with greater ease. It also enables the operator to bring the 
posterior pillar into easy access of the tonsil knife. 




Tlie author's tonsil forceps. 



(c) Dissect the anterior ]jillar from the tonsil and carry the incision 
above the margosupratonsillaris, or the supratonsillar space, to the 
posterior pillar (Fig. 243). The aim should be to dissect around the 
u])per half of the tonsil, removing the mucous membi'ane forming the 
roof or dome of the supratonsillar fossa. These details are important 
iflitjis the intention to remove the tonsil with its fibrous capsule intact. 
The incision thus assumes the form of an inverted U. The instrument 



39S 



THE PIIARYXX A. YD FAUCES 



used is the Kyle ri<rht-an(rle tonsil knife shown in Fig. 244. It should 
he hooked into the mucosa at the junction of the anterior pillar with 
the plica triangularis. It is then pulled toward the median line of he 
throat, tlius severing the pillar from the plica triangularis and the tonsil. 




The tonsil is grasped with the author's vulsellum tonsil forceps, the upper prong tips being 
Itlaoed in the supratonsillar fossa, and the lower prong tips at the base of the tonsil; thus grasped 
the tonsil is drawn toward the median line of the fauces preparatory to removal by dissection. 

Re-introduce the hook blade into the incision thus made and engage it 
as before, and pull toward the median line. Two or three such cuts are 
required to bring the incision aliove the supratonsillar fossa. While the 
foregoing incision is l^eing made the tonsil is in the grasp of the vulsellum 
forceps, and it is pulled forcil)ly toward the median line. This puts the 
pillar upon the stretch and greatly facilitates its separation from the 
tonsil with the hook knife. 

The posterior pillar should next be separated in nuich the same 
manner. This pillar is not as accessible as the anterior one, but it can 




The primary incision being made with the right-angle crypt knife. The knife is introduced 
tlirough the mucous membrane at the junction of the anterior pillar, and the plica triangularis 
upon I)eing milled forward makes tlie incision b; the knife is again introduced through the incision 
as shown (a) in the ilhistiation. Tlie incision is thus completed by three or four cuts with the 
knife. 



be brought into view by rotating (he h; 
thereby turning the tonsil upon its latera! 



(He of the vulsellum forceps, 
ixis in such a wav as to brina; 



TONSIL OPERATIONS 



399 



the posterior pillar forward, where it is readily accessible to the hook 
hiife (Fig. 245). 




Showing the duection of the posterior pillar from the tonsil with the right-angle knife. The 
tonsil is turned toiward upon its lateral axis with the author's vulsellmn forceps to bring the 
pillar upon the upper surface, where it is accessible to the knife. 

The two incisions should be united above the margo-supra tonsillaris. 
Observe carefully the margin of mucous membrane forming the roof of 
the supratonsillar space and make the incision just above it. 

The combined incisions are thus converted into a U-shaped incision. 

(d) Again seize the tonsil with the vulsellum forceps, with the upper 
prong tip introduced into the supratonsillar portion of the incision and 
the lower prong tip at the base of the tonsil. The tonsil is thus well 
within the grasp of the forceps and is ready for the dissection with the 
hook knife. 




if ilissectiim willi Kyle's crypt knife. During tlie dissecti 
d \\\r median line of the fauces witli tlie autlior's vulsellum 



(e) Pull the tonsil toward the median line, thereby putting the 
fibers attaching it to the suj^erior constrictor muscle upon a tension. 
With the hook knife sever the fibrous bands (Fig. 240), following the 
external contour of the tonsil to its inferior portion. It is rarely necessary 



400 



77/ A' PJIARYXX AM) FAUCES 



to <lrv the wouikI (hirin^r tlic operation, i)rovi(liiio- the eocaiiie-a<h"enaUn 
sohition is injeeted. If anesthesia has heen indueed by brushing the 
tonsil with cocaine there may be considerable hemorrhage. 



Fig. 247 




The audior's tonsil ecraseur. a substitute for the snare. 
Fio. 248 




'J'lie tonsil a in the grasp of the author's tonsil force] 
enucleated by dissection will 



le up 

ilisuli 



ilf nf the tonsil u has been 



(/) At this stage of the operation the use of the knife may be abandoned 
and the author's ecraseur tonsillotome substituted (Fig. 247) to complete 
tlie operation This shortens the time of operation, though it may be 
completed with the knife. 



TONSIL OPERATIONS 



401 



(d,) Pass the forceps through the rmg blade of the ecraseur and 
seize the tonsil, then pass the ecraseur over the tonsil as shown in 
Figs. 248 and 249. Close the instrument and thus complete the 
operation. The dull ring blade of the ecraseur readily passes behind 
the tough fibrous capsule of the tonsil and makes a clean dissection of 
its lower portion. 




The final step of the tonsillectomy as performed with the author's tonsil ecraseur, 
a substitute for the tonsil snare. 

The wire snare, on the contrary, tends to cut through the capsule and 
leave the low^er portion of the tonsil in situ. 

If hemorrhage follows the operation, it may be controlled by swabbing 
the sinus tonsillaris with a solut'on of the permanganate of potash, | to 
1 grain to the ounce of water. The peroxide of hydrogen may also be 
used for the ^ame purpose. Stronger remedies are rarely required. 
Continuous gargling with iced water often controls it. Tonsil clamp 
forceps (Figs. 250 and 251) need rarely be used. 




(Iciirral ReuKirks-. — The operation is ])crfoniu'(l under cocaine anes- 
thesia in adults, injections being made as described in Fig. 252. The 
Kyle knife should \)v very sliiirp. If dull, it cuts witli such hesitancy 
26 



402 



THE PHARYNX AND FAUCES 



that it is very disaureoable to the patient. In making the primary 
iiu'ision the tonsil should be grasped with the forceps, one blade being 
in the supratonsillar fossa and the other at its base. The handles of the 




Boetcher's tonsil hemostat. 



Fig. 252 



forceps should then be closed and 
locked. The tonsil is then drawn 
toward the median line of the 
fauces during the dissection. The 
tension thus exerted renders the 
mucous membrane taut, and the 
dissection easy. In making the in- 
cision at the upper portion of the 
posterior pillar (Fig. 245), the tonsil 
should be twisted forward and 
downward on its horizontal axis to 
bring the posterior pillar into easy 
access of the knife. 

The advantage of the author's 
tonsil ecraseur over the tonsil snare 
is, that it is always ready for use, 
whereas the wire of the snare needs 
adjustment each time it is used. 
When two tonsils are to be removed, 
the wire for the snare must either be 
straightened or another one inserted 
before the second tonsil can be re- 
moved. This is not true of the ecra- 
seur, as it is always ready for use, 
like an ordinary tonsillotome. The 
edge of the fenestrated blade is round, 
thus conforming to the cutting sur- 
face of a wire. (Sharp blades are 
also furnished with the instrument.) 
If there is less hemorrhage following dull dissection, the ecraseur 
meets this requirement. The same is true of the cold-wire snare. After 
many dissections with the ecraseur, I have rarely known it to fail to 
complete the dissection of the tonsil with its capsule intact. 




Schema showing the points of injection of 
adrenalin and cocaine solution preliminary to 
the removal of the tonsil with its capsule intact. 
About 2 minims of the solution is injected at 
each point. 



TONSIL OPERATIONS 



403 



This method of removing the tonsil with its capsule intact, while not 
based upon as good surgical technique as the author's method with a 
scalpel, is easier to perform by the average operator than the dissection 
with the scalpel. Personally, I prefer the scalpel dissection, because I 
can do it in much less time, with less hemorrhage, and less discomfort 




to the patient. I also prefer the scalpel dissection, because I believe the 
wound after a clean dissection with a sharp knife heals more kindly and 
quickly than the wound left after a dull dissection. 

Tonsillectomy with a Scalpel. — The Author's Operation. — After having 
tried almost every known method of removing the tonsils, the simplest 
of all instruments has been found to be the best adapted for the purpose. 
A common scalpel (Fig. 253), such as is used in making the mastoid 
and abdominal incisions, is the instrument now used in all cases. 
The only other instrument required is the vulsellum forceps (Fig. 242). 
A tongue depressor is not used, as the forceps crosses the tongue and 
keeps it out of the way. 




Tlic first incision in tlie remfival of tlie tonxii witli its capsule intact. The tonsil is tirawn 
forward and inedianwaid from the sinus tonsillaris. The incision is extended, as shown in Fig. 255, 
a very sharp scalpel being required for tlie purpose. 

Technique. — (a) Anestliosia by tlie injection of the cocaiiic-adi-enaliii 
solution (Fig. 2.52). 

k (6) Seize the tonsil witli vulsellum forceps, one blade in the supra- 
tonsillar fossa, the other at its base, as in the preceding method. Pull 



404 THE PllARYSX AM) FAUCES 

the tonsil mediaiiAvanl and torwanl to dislodge the anterior shoulder 
from beneath the anterior pillar. This pulls the posterior margin of 
the pillar forward and faeilitates the intrcduction of the scalpel l)et\veen 
it and the tonsil. 

(c) Introduce the blade of the scalpel to a depth of about one-half 
inch between the anterior pillar and the tonsil at the junction of the 
pillar iuid plica tonsillaris (Fig. 254). Sweep the blade upward to the 
margo-supratonsillaris, and thence over the margo-supratonsillaris to the 
posterior pillar (Fig. 255). The knife should be very sharp for this 
purpose. This completely severs the tonsil frcm the anterior pillar and 
exposes the outer aspect of it to further dissection. By including the 




The author's operation for the removal of the tonsils with its capsule intact, a b, the line of 
incision beginning at 6, at the junction of the anterior pillar and the plica tonsillaris (c) and 
extending upward to the upper lobe of the tonsil, thence forward so as to include the margo- 
supratonsillaris to a. The incision of the margosupratonsillaris liberates the upper or velar lobe 
of the tonsil and greatly simplifies the operation. 

margo-supratonsillaris in the incision (the blade being in the tissues to the 
depth of about one-quarter inch) the upper portion of the tonsil concealed 
in the supratonsillar fossa is freed from its attachments. If this step of 
the operation is not observed, the dissection is more difficult. 

(rZ) Continue to pull upon the tonsil with the forceps, and its capsule 
may be seen through the incision. Then introduce the knife through 
the upper part of the incision and hug the tonsil capsule and sever it 
from its attachment to the superior constrictor muscle, as shoAMi in 
Fig. 256. The branches of the tonsillar artery are severed in this step 
of the operation. They are small and do not often give rise to trouble- 
some hemorrhage. If, however, some of the fibers of the superior con- 
strictor muscle are accidentally removed, the main stem of the artery is 



TONSIL OPERATIONS 



405 



severed and the hemorrhage may be severe. If the hemorrhage is 
severe, the bleeding points should be seized with artery forceps. 

(e) Disengage the vulsellum forceps from the tonsil and place one 
prong tip into the anterior aspect of the wound the other over the inner 




The tonsil being separated from the bed of the sinus tonsillaris, to which it is loosely attached, 
the capsule is hugged with the author's scalpel, care being exercised to avoid injuring the 
superior constrictor muscle which forms the bed of the sinus tonsillaris. 

aspect of the tonsil, and close them upon the tonsil (Fig. 257). Tract the 
anterior border of the tonsil toward the median line of the throat, using 
the posterior pillar as a hinge. 

( /) Then, having rendered the posterior pillar accessible, shave it 
free from the posterior border of the tonsil with the scalpel (Fig. 253). 
Great care should be taken to avoid injury to the muscular tissue of either 




IP tons 
knife. 



IS drawn tr 
The pillar 



the median line of the throat to expose the posterior pillar to the 
ised to the bottom of the tonsil at its junction with tiie tonsil. 



the anterior or posterior pillars during the dissection. If the muscles 
are not injured, there is little liability to hemorrhage from these regions, 

iis the ;ivl(M'v is within the muscnlnr substance of the pillars. 



406 THE PHARYNX AND FAUCES 

(g) The tonsil is now only attacked at its inferior portion. While 
still pulling the tonsil toward the median line of the throat complete the 
dissection by cutting downward and inward. The tonsil is thus removed 
with its capsule intact. The first incision separates the anterior pillar 
and the plica supratonsillaris from the anterior and superior surfaces 
of the tonsil. The second separates the outer surface of the tonsil from 
the superior constrictor muscle of the pharpix. The third separates 
the posterior pillar from the corresponding border of the tonsil. The 
fifth incision completes the dissection by freeing the inferior attachment 
of the tonsil from the pharjugeal wall. 

Since adopting this method of operating I have seen no alarming 
hemorrhages except in one instance, in which I injured some fibers of 
the superior constrictor muscle of the phar\aix. The hemorrhage was 
primary and was easily controlled by a solution of permanganate of 
potash (I gr. to the ounce of water). 

The Complete Removal of the Tonsil with the Capsule Left in Situ — Some 
operators (Robert C. ^Nlyles, Geo. B. Wood, and others) prefer to leave 
the capsule of the tonsil in the sinus tonsillaris, as they believe there is 
less liability to severe infection of the wound following the operation. 







They also believe the hemorrhage to be less profuse. While I agree 
with these views, I have hesitated to advocate this method of tonsillectomy, 
because I fear the average practitioner would fail to remove all of the 
substance and crypts of the tonsil. If he would remove all of the paren- 
chyma of the tonsil, including every vestige of the walls of the crypts, 
I would commend this method of tonsillectomy above all others. The 
temptation seems to be inherent in the operator to declare that what he 
has done has been complete, and all that could be desired, even though 
the work is but poorly or incompletely done. If I can sufficiently 
em])hasize the importance of the total ablation of the substance of the 
tonsil, including the walls of the crypts, the bottoms of which lie in 
ap])osition with the buried capsule of the tonsil, I am ready to advocate 
tlvs method of removing the tonsil. 

Technique. — (a) Cocaine anesthesia, as shown in Fig. 252. 

{b) Remove as much of the tonsil with the tonsillotome (P'ig. 258) as 
possible. 

(c) Remove the remaining substance of the tonsil with the ^lyles, 
the Reault, the Rhodes, or other models of tonsil punch forceps (Fig. 259). 
From time to time during the operation search for remnants of the crypts 
w'th a blunt probe (Wood). When they are found, remove more tissue 



TONSIL OPERATIONS 407 

with the tonsil forceps or a sharp curette, and so continue until the crypts 
are totally obliterated. 

Casselberry called attention to the advantage of dividing the mucous 
membrane along the margo-supratonsillaris. He claimed that this 
procedure rendered the liberation of the velar lobe, or supratonsillar 
portion of the tonsil, much easier and more certain. Without knowing 
of Casselberry's recommendation, I arrived at the same conclusion, 
though my technique is quite different from his. 

By my method the mucous membrane is divided at the junction of the 
plica triangularis and the anterior pillar, and the incision is then extended 
along the margo-supratonsillaris to the posterior pillar, as shown in Fig. 
255. If this preliminary incision is thus made, the subsequent steps of 
the operation will be more easily accomplished; indeed, the dissection 
of the tonsil is nearly consummated by this procedure alone. 

Robertson's Operation. — Robertson's method of removing the tonsil is 
as follows: (a) General anesthesia preferred. 




Myles' tonsil punch forceps. 

(b) The anterior and posterior pillars are first separated from the tonsil 
with a curved double-edged knife, or, if the pillar is adherent, with his 
pillar scissors. 

(c) The tonsil is then grasped with forceps and pulled forward and 
inward, the scissors pushing the pillars back out of the way. The 
scissors are then closed and the tonsil removed by a series of cuts (Figs. 
260 and 261) . The tonsil upon the opposite side shows the position of 
the tonsil before it was pulled from its sinus. 

This operation may also be performed under local anesthesia, as in 
the author's method. It may also be removed in its entirety with its 
capsule intact by this method. The tonsil scissors are made in pairs to 
adapt them to either tonsil. This method of removing the tonsils is 
thorough and commendable. The prime question in reference to any 
tonsil o])cration is in reference to its completeness. 

Pynchon's Cautery Dissection Operation. — According to Pynchon, this 
method of removing the tonsil in its entirety possesses the advantages of 
(a) Init slight or no primary hemorrhage, and (h) the sealing of the wound 
by the eschar, thus prev(Miting sev(M-e infect'on of the wound. 



40S 



THE PITAEYXX AXTi FAUCES 



Techuique. — (o) I>ocal anesthesia is induced by repeated swab- 
l)ings with a 10 per cent, sohition of cocaine, ending with a 20 per cent. 




Robertson's tonsil scissors. The scissors come in pairs. 

.sohition. To each solution of cocaine should be added one-half as much 
carbolic acid as cocaine. If preferred, the anesthesia may be induced 
by injection of cocaine and adrenalin. 

{h) Seize the tonsil with mouse-toothed forceps at about the central 
portion and pull it inward and backward, thus putting the plica tonsillaris 
and the anterior pillar upon a tension. This renders the anterior border 
of the tonsil easily discernible. 




i 



s scissors. 



(c) With a nearly straiglil cautery electrode at a cherry-red heat 
puncture the membrane at the junction of tlie anterior pillar and the 
])lica tonsillaris about one-third ihe distance from the top of the tonsil, 
and dissect downward to the tongue. Then dissect upward over the 



TONSIL OPERATIONS 409 

margo-supratronsillaris and a little way down the posterior junction of 
the tonsil and pillar (Fig. 262). In other words, make the incision 
shown in Fig. 255. 

(d) With a nearly right-angle electrode (Fig. 262) complete the dis- 
sect'on of the posterior pillar from the tonsil. 

(e) Pull the top of the tonsil inward and downward, and dissect it, 
with the electrode, from its attachment to the superior constrictor muscle, 
thus freeing it from the sinus tonsillaris. 

(/) The remaining pedicle, at the base of the tonsil, is severed by 
stretching it over the heated electrode. 

(g) Only one tonsil is removed at a sitting, the remaining tonsil being 
removed in about two weeks, or after the first tonsil wound has healed. 

(h) Applications of a 20 to 30 per cent, aqueous solution of the nitrate 
of silver may be made from time to t'me during the operation to check 
oozing hemorrhage. 




The removal of the tonsil by cautery dissection by Pynchon's method. 

({) The after-treatment should consist in the use of alkaline and 
aromatic gargles and the daily application of the following mixture: 

I^ — Tr. iron, 

Glycerin aa 5J 



The above mixture should be rubbed into the wound with a cotton- 
wound applicator to prevent infection and exuberant granulations. The 
wound should heal with a smooth surface and without the formation 
of cicatricial bands. If the muscular tissue of the pillars is injured, 
contriicturc and disagreeable deformity of the fauces may result. 

Tonsillotomy. — The author has elsewhere expressed his views as to 
tlic ])n)pricty of removing a portion of the tonsil, l)ut inasmuch as it is a 
time-honored proce(hire, and is likely for various reasons to be ])ractise(l 
ill the future, it will be descnl)ed in this chapter. 

Technique. — (a) The operation may be done iukUm- either local 
cocaine anesthesia or general anesthesia. 



410 



THE PHARYXX AXD FAUCES 



(h) If the subject is an infant or a young child, and the operation 
is to be performed under either local or nitrous oxide gas or bromide 
of ethyl anesthesia, he should be held in the lap of an assistant. 




Tongue depres: 



He should be wrapped in a sheet tightly pinned around his body 
and arms, while his head should be grasped by the assistant's left 
arm and hand. The legs of the assistant should be crossed over those 
of the child to prevent struggling during the operation. If a general 
anesthetic is administered, one arm should be left exposed to test the 
pulse and the muscular reflexes. 

(c) A mouth gag may or may not be used according to the discretion 
of the operator. 

(d) Depress the tongue with a tongue depressor (Fig. 263) to expose 
the tonsil to full view. 




Farlow's tonsil punch 



(/') Introduce the tonsillotome into the mouth of the child, place the 
ring blade over the tonsil, and forcibly push it outward, and at the same 
time move the ring blade up and down to engage the tonsil. 



TONSIL OPERATIONS 



411 



(/) When the tonsil protrudes through the ring blade close the instru- 
ment and thus cut off as much of the tonsil as happens to protrude 
through it. 

It occasionally happens that all of the tonsil with its capsule intact is 
removed by this method of operating. More often only a portion of the 
tonsil is removed. The upper portion of the tonsil is often quite inacces- 
sible to the ring knife, and as this usually contains the more diseased 
crypts the operation is but partially effective. 

The remaining portions of the tonsil may be removed with punch 
forceps, preferably of the Reault, Farlow, or Rhoades type, as shown in 
Fig. 264. 

The Complications and Sequelae of Tonsil Operations. — Inasmuch 
as the tonsillectomy is, or should be, performed as often in adults as 
in children, the question of post- 
operative hemorrhage and of in- Fig. 265 
fection becomes an important one. 
In children hemorrhage and in- 
fection of a severe type are rare, 
whereas in adults they are much 
more common, on account of the 
larger development of the vessels 
and the greater abundance of 
fibrous connective tissue, which 
offers less resistance to microbic 
infection. 

Hemorrhage.— (See Fig. 265 and 
page 374.) 

Infection. — ^The infection follow- 
ing tonsil operations is usually 
more severe and prolonged in 
adults than in children. In chil- 
dren the temperature is elevated 
one-half to two degrees for two 
to five days, whereas in adults 
it is often more highly elevated for 
from two days to a week or more. 
The soreness in children is usually limited to three or four days, while 
in adults it often continues longer. If the infection was only thus mani- 
fested it would be a matter of small importance. Unfortunately, it is 
occasionally so severe as to be alarming, even to the point of actual 
danger to life itself. While I have never seen a case result in death, 
I have seen a few assume alarming symptoms. That is, I have seen 
two cases in about 5000 tonsil oj)erations in which the hemorrhage 
was so prolonged that marked anemia and exhaustion resulted, and two 
of severe sepsis from streptococcus infection. 

If the cases with secondary hemorrhage had been operated in the 
hospital, the bleeding c-ould have been more quickly controlled and the 
danger averted. 




r:^^ 



Showing the bleeding points after adult tonsil- 
lectomy, a, the anterior pillar; b, the tonsillar 
plexus of veins at the inferior portion of the sinus 
tonsillaris; c, the central portion of the sinus ton- 
sillaris, where the tonsillar artery enters the tonsil; 
d, the posterior pillar, c represents the most com- 
mon site of hemorrhage (see page 374). 



412 THE PIIARYXX AXD FAUCES 

In one of the septic cases the removal of the tonsils was clone by 
l)artial dissection and completed with a snare, whereas in the other case 
the dissection was done with a sharp scalpel. In the latter case the 
infection was the more severe of the two, a fact which apparently con- 
troverts my previons statement that a clean-cut dissection is less apt to 
be followed by infection than a dull-cut or crushing dissection with a 
snare. In spite of the apparent discrepancy between this statement and 
the result in the case referred to, I wish to reaffirm my previous statement 
that dissection with a sharp instrument is less liable to be followed by 
severe secondary infection than one made with dull-cutting or crushing 
instruments. Ant)ther factor which must be taken into account is the 
virulence of the infective microorganism causing the infection. If a 
virulent type of streptococcus is the infective agent, the resulting infection 
and sepsis will be severe, no matter what method of dissection is used. 
Crushed tissue is less resistant than tissue cut with a sharp instrument, 
hence it is more readily infected, though either may be the seat of infec- 
tion. The whole question is one of the microorganism on one side, and 
of the tone or resistance of the tissues on the other. If the resistance of 
the tissue is normal and the virulence of the microorganism is great, 
infection will follow. If the resistance of the tissue is low and the viru- 
lence of the microorganism is low, there may or may not be infection, 
according to the balance or imbalance existing between the resistance of 
the tissues and the virulence of the infecting microorganism. It follows, 
therefore, that the question of infection is not wholly dependent upon 
whether the dissection is performed with blunt or with sharp instruments, 
but that the general tone of the tissues previous to the operation, the 
local tone as affected by either blunt or sharp instruments, and the viru- 
lence of the invading microorganism each has its influence in determining 
the severity of the infection and the resulting sepsis. 

An analytical statement of the chief factors influencing the severity 
of the infection and sepsis following the removal of tonsils in adults is 
as follows : 

1. The general tone of the cellular and fluid tissues of the body. 

2. The local tone as influenced by local disease and by the character 
of the dissection (dull or sharp). 

3. The virulence of the microorganism. 

The practical deductions to be drawn from the foregoing analysis 
are as follows : 

1. If the patient's vital forces are low, tonics and fresh air should be 
prescribed for some time before the operation. It is true that it is not 
often advisable to delay the removal of the tonsil until the general tone 
of the system is elevated, as the tonsils may be the direct cause of the 
lowered vitality of the patient, and should be removed to stop the 
toxemia. Under such circumstances the risk of the infection and sepsis 
must be assumed, and such measures adopted as will avert or minimize 
the intensity of the two processes. 

2. The resistance of the tissues is influenced by the previous local 
disease, and by the character of the dissection. The local changes due to 



TONSIL OPERATIONS 413 

previous disease of the tonsil cannot, perhaps, be ehminated, and, in 
so far as this factor is concerned the operation must be performed in 
spite of it. In so far as the tone of the local structures is affected by 
the character of the dissection, this is entirely under the control of the 
operator. He can avoid the use of crushing instruments by substituting 
sharp ones. While this precaution will not always prevent infection 
and sepsis, it will reduce the number and severity of the infection. 

3. The virulence of the local microorganisms present in the throat 
may be determined before the operation by the adoption of the routine 
practice of making cultures from the tonsils. This is not always practi- 
cable, but when it is it should be done. Another way of arriving at much 
the same result is to carefully inspect the tonsil, especially the crypts 
in the supra tonsillar fossa and those covered by the plica triangularis, 
and note the local signs of irritation and inflammation, especially redness 
of the mucous membrane. Still further information may be obtained 
by questioning the patient as to the presence of soreness or pricking upon 
swallowhig. If these signs are present, it is wise to defer the operation 
until the crypts are cleaned out and the local irritation and inflammation 
have subsided. 

There is a possibility of severe infection following the removal of 
tonsils, even in cases in wh'ch there is no apparent inflammation. 
Virulent germs may be lodged in the bottom of the crypts without 
giving rise to obvious symptoms. Close inquiry might elicit the state- 
ment that the patient has a slight soreness upon swallowing, a sensation 
of pricking. In one such case in the author's practice a most violent 
and obstinate infection occurred. The patient, a rhinologist, came for 
the removal of his tonsils, and inasmuch as I presumed he knew wdiether 
his throat was in a proper condition for the operation, the tonsils were 
removed. After the occurrence of the infection he told me that he had 
been suffering for a week from a slight soreness or pricking in the throat. 
These facts all go to show that the surgeon should not presume anything, 
even though the patient is supposedly well informed concerning his 
condition. x\ll cases should be subjected to close scrut'ny by the surgeon 
before performing an operation. 

Should the examination show such soreness to be present, the operation 
should not be performed. The crypts of the tonsils should be cleansed 
of all debris by syringing (Fig. 266) with a warm normal salt solution. 
A curved cotton applicator moistened with the tincture of iodine should 
be introduced into each crypt to allay any infection and inflammation 
present in them. Treatment thus carried out for one week will usually 
prepare the tonsils so that the operation may be performed without the 
danger of infection of tonsillar origin. It is urged, therefore, that sur- 
geons should always prepare the tonsils for operation, just as he would in 
any other part of the body. The same rule should be applied to the nose, 
throat, and larynx, even though these regions are not susceptible to 
absolute surgical cleanliness. The breeding or incubating foci can at 
least be gotten rid of. Since the exceptional experience referred to in 
the preceding paragra})li, the au hor has made it a routine practice 



414 Till-: I'UARYXX AM) FAUCES 

to tlior()U<>lily irrigate the crypts of the tonsils before operating, and if 
obvious signs of infection and inflammation are present the tonsils have 
been sul)jected to treatment for at least one week before removing the 
tonsils. 

Is Tonsillectomy a Hospital Operation? — In young children it is not 
necessarily a hospital operation, as it is rarely followed by either severe 
hemorrhage or sepsis. In adults it should be a hospital operation, on 
account of the possible hemorrhage and sepsis. 

A prominent surgeon has said that the tonsil is of greater clinical 
ini])ortance than the appendix; that it causes more suffering and more 
deaths. If this is true, and I believe it is, the tonsil is worthy of the most 
serious and ])ainstaking study. 



=^)=I 




The author's tonsil syringe. 

The technic^ue of its removal should receive the same careful and 
patient attention that has been devoted to the removal of the vermiform 
a})pendix. In view of the importance of the tonsil from a clinical stand- 
point, and in view of the possible complications and sequeltie following 
its removal, tonsillectomy should be regarded as a hospital operation. 
If performed in a hospital the danger from primary or secondary 
hemorrhage is largely eliminated, and infection and sepsis may be di- 
minished in severity and in the frequency of their occurrence. 



I 



i 



CHAPTEK XXIV. 

NEOPLASMS OF THE TONSIL. 
BENIGN NEOPLASMS OF THE TONSILS. 

Benign tumors do not occur as often in the tonsils as they do elsewhere 
in the pharynx. Of the variety found in this region, papilloma is the 
most common. 

Papilloma. — Papilloma is more often multiple than single, and presents 
the general outlines of a bunch of grapes. If single and large it may 
be mistaken for a supernumerary tonsil. Like all papillomata it has 
a tendency to return, and is sometimes converted into malignant 
epithelioma. It should, therefore, be removed by clean surgical excision, 
rather than by a crude crushing method, as with a snare or dull 
forceps. It should be borne in mind that the transition from a benign 
papilloma to a malignant epithelioma is, histologically, rather easy. 
The epithelial growth in the papilloma is outward, whereas in epithe- 
lioma it is inward. There are, of course, other histological differences. 
The structural arrangements are, however, so similar as to warrant a 
certain amount of caution and discretion in their diagnosis and surgical 
treatment. 

In some instances there may be one pedicle with many individual 
papillomata attached, whereas in others there may be many pedicles. 

The growths, as a rule, give rise to no marked symptoms. A slight 
hacking cough, a tickling sensation, and the feeling of a foreign body in 
the faucial region is complained of. The only change noted in the 
surrounding tonsillar tissue is an increased hyperemia around the attach- 
ment of the tumor. Pain is never present. The tumors vary in size 
from a pea to that of an enlarged tonsil. 

Lipoma. — Lipoma of the tonsil is rare, though Atkinson, Farlow, 
Ingalls, and others have reported cases. They are fatty tumors, and are 
innocent. 

Angioma. — Angioma of the tonsil is also quite rare. Flatau, Phillips, 
Bosworth, Keimer, and others have reported a few cases. 

Treatment. — The treatment is preferably by electrolysis, the positive 
pole being applied by means of gold-plated needles thrust into the neo- 
plasm. The current strength should vary from 5 to 25 ma., and should be 
applied for from two to twenty-five minutes at each seance. Repeat the 
applications once or twice a week until the vascular grow^th is obliterated. 

Fibroma. — Fibroma of the tonsil is a benign neoplasm next in fre- 
quency of occurrence to papilloma. It very rarely becomes malignant. 
Its growth is very slow, and is usually limited to one tonsil. Delevan 



416 'I'm- PIIAinXX AX I) FAUCES 

and others have .sut>;(i;e.ste(l that Hhi'ous ttimors of the tonsils may be 
mistaken iov supernumerary tonsils. This is especially true if the super- 
numerary tonsil acquires its fihrous tissue from the degenerative changes 
due to a constant irritation from its exposed position in the fauces. 
Technically it is a fihr()})lastie fibroma. Some claim it is only a 
fibroma which happens to incorporate some of the lymphoid tissue in 
pushing out from the tonsil. 

Etiology. — Fibroma of the tonsil occurs equally often in each sex, and 
j)erhaps more often in the young than in middle and advanced age. 

Pathology. — Fibroma is usually somewhat pedunculated, though it 
may be sessile. The larger the fibroma the larger the pedicle. Tim- 
are more often single than multiple. Being of connective tissue of 
mesoblastic origin, it must of necessity have its origin from the trabec- 
uLie of the tonsil. Occasionally it undergoes cystic degeneration. 
Usually it is firm and scantily supplied with vascular structures. It is 
com])osed of white fibrous tissue, the cells often being matted together, 
closely sinudating embryonic connective-tissue cells. 

Symptoms. — Annoying symptoms are seldom present, except in the 
large pedunculated type, when it produces mechanical obstruction. Its 
presence is not accompanied by discharge. It is characterized by symp- 
toms similar to those of enlarged or hypertrophied tonsils. 

Diagnosis. — The diagnosis is usually easily made, and in case of doubt 
a portion should be excised and submitted to microscopic examina- 
tion. 

Treatment. — The treatment is purely surgical and consists in its 
removal, a procedure easily accomphshed if the growth is pedun- 
culated. Occasionally it may be adherent to the tonsil or to the neigh- 
boring structures as a result of repeated inflammations of the tonsil. 

Surgical Technique. — (a) Cocainize the growth and the area around 
the point of attachment with a 10 per cent, solution of cocaine by 
repeated swabbings. 

(b) Separate the points of adhesion wdth a scalpel or scissors. 

(c) Pass a cold-wire snare around the tinnor, engaging it at its 
pedicle, or point of attachment. 

(d) Sever the pedicle by closing the wire loop. 

(e) Cauterize the stump of the pedicle, and if it penetrates the tonsillar 
tissue, dissect it to its point of origin. 

(/) Fre(]uent cleansing with some antiseptic gargle should be practised 
for about one week, or until healing takes place. 

(g) Instead of using the wire snare as given in (c), the growth may be 
seized with the vulsellum or other toothed forceps and dissected with a 
scal])el from its attachment to the tonsil. 

Fibro-enchondroma. — A few cases have been described, and notable 
among tluMii is that of Cosolini, which was as large as an orange and 
was readily eiuicleated. (Irosvenor reports one case. 

Cystoma. — Cystoma of the tonsil is rare. It may be either super- 
ficially or deeply situated. Virchow reports liaving found them post- 
mortem. 1 have occasionally found them of small size when enucleating 



MALIGNANT NEOPLASMS OF THE TONSILS 417 

hypertrophied tonsils. They vary in size, and may contain a quantity 
of fluid or a mass of inspissated secretions and epithelial debris. 

They give rise to no peculiar symptoms other than those usually 
present in enlarged tonsils. 

They may be eradicated by freely incising them with a bistoury and 
curetting the lining membrane, and then swabbing the cavity with pure 
carbolic acid to excite reactionary inflammation and agglutination of 
their opposed walls. A still better method of treatment is to enucleate 
the tonsil as described under Tonsillectomy. 

Lymphadenoma in Hodgkin's Disease. — In every case of Hodgkin's 
disease it is advisable to examine the tonsils, as they may be the seat 
of a lymphadenoma such as is present in other parts of the body. In 
the early stage of the disease it may be impossible to positively assert 
that the tonsils are involved, though they may appear abnormally en- 
larged. In the author's case the tonsils did not appear to be enlarged. 
By keeping the case under observation their growth may become ap- 
parent, and when it occurs is quite significant. Lymphadenoma of 
the tonsil is only a local expression of a disseminated lesion of a similar 
nature throughout the general lymphatic system. In my case the ton- 
sils were not apparently involved, though the neck glands were enor- 
mously enlarged. The case improved markedly under the application 
of the Rontgen rays. 

MALIGNANT NEOPLASMS OF THE TONSILS. 

Carcinoma of the Throat. — According to some authorities carcinoma 
is more frecjuently found in the tonsils than sarcoma, while others 
hold the reverse to be true. More than 100 cases have been recorded, 
and according to Bosworth it occurs once in every 2000 cases of carcinoma 
in all parts of the body. It is a disease of middle and advanced age, 
though J. D. Bryant reports a case occurring in a patient aged seventeen 
years. Sarcoma may occur at any age, but more often in early life. The 
youngest case coming under my observation occurred at the eighteenth 
month. Cases of sarcoma have been reported as late as the eightieth 
year. The average age at which carcinoma appears is about the fifty- 
second year. 

Carcinoma of the tonsil is more malignant than sarcoma because of 
the liistopathological predominance of glandular epithelium. It is 
rarely primary, but is usually secondary to carcinoma of the tongue or 
pillars of the fauces. It is usually characterized by a squamous and 
spindle cell epithelium. It does not attain the large size of sarcoma of 
the tonsils, but it involves the neighboring lymphatic glands at an earlier 
])(M-i()(l. 

Symptoms of Carcinoma. — Early ulceration, a fetid breath, more or less 
pain of a lancinating character, emaciation, and cachexia are the usual 
symptoms. Before ulceration the secretions are of a heavy mucous 
nature, while after ulceration they are often purulent in character. Slight 
hemorrhage is a frequent symptom. It may, however, in exceptional 
27 



418 THE PIIARYXX AXD FAUCES 

cases, he very profuse and cause death. Edema of the glottis is fre- 
tjuently present; indeed, one might say it is an ahnost constant concomi- 
tant compHcation of carcinoma of the tonsil in the advanced stage. 

Pain is always aggravated during the act of swallowing, and the voice 
is either hoarse or aphonic. Secondary glandular involvement is an 
early feature (Fig. 234). The subjective symptoms are very little 
different from those of sarcoma of the same region, except in the ad- 
vanced stage, when ulceration and pain are present. 

Diagnosis. — Carcinoma of the tonsil is a disease of middle and advanced 
life, while sarcoma more often occurs in the young. Ulceration occurs 
early in carcinoma and later in sarcoma; carcinoma is nodular, while 
sarcoma is smooth and round. Carcinoma has a fleshy pink hue and 
is often fimgoid, while sarcoma is blue in color and is crossed by rather 
large arteries. 

When in the state of ulceration carcinoma may be mistaken for syphilis, 
particularly if the adjacent glands are not much involved. 

The progress of the case and the administration of the iodides will 
soon clear the diagnosis. 

The pain in carcinoma is lancinating and sharp, while it is dull and 
periodic in sarcoma. 

Papilloma is painless, pedunculated, seldom idcerates, and secondary 
involvements by direct extension of metastases do not occur. There are 
no constitutional symptoms, and the growth is multiple and presents 
the appearance of a bunch of grapes. 

Fibroma of the tonsil has a constricted l)ase, grows very slowly, is 
free from pain and glandular involvement, and does not recur when 
removed. 

A microscopic examination of the tissue should be made in differen- 
tiating the various types of tumors. 

Differential Diagnosis of Sarcoma and Carcinoma of the Faucial Tonsils. 

Sarcoma. Carcinoma. 

1. Any age, most often after fifteen. 1. Not in early life, usually after forty. 

2. Frequently primary. 2. Rarely primary. 

;}. (ilandular involvement late. 3. Glandular involvement early. 

4. I'Vequontly encapsulated. 4. Not encapsulated. 

5. Vascular, hemorrhages, ulcerates 5. Not so vascular, scant hemorrhage, 

early. ulcerates late. 

H. Fre(iuent in males. 

Treatment. — The treatment of carcinoma and sarcoma of the tonsil is 
))alliative and surgical, though in most cases the latter affords little 
encouraijement. 



EXTIRPATION OF THE TONSIL BY THE EXTERNAL ROUTE. 

In malignant disease of the tonsils where the sin-rounding tissues 
have become involved it may become necessary to remove the tonsil by 
the external route, or von Langenbeck's method. 



EXTIRPATION OF THE TONSIL BY THE EXTERNAL ROUTE 419 

Technique. — (a) General anesthetic. 

(6) The external incision is in the form of a U, thus making a tongue- 
shaped flap (Figs. 267 and 268). The flap thus made lies immediately 
over the ascending ramus of the lower jaw. This portion of the jaw 
is to be temporarily resected, so as to expose the tonsil region to operation. 

(c) The external maxillary artery (facial) is ligated to control the 
hemorrhage. 

(d) The periosteum corresponding to the anterior incision should be 
divided preparatory to sawing through the bone. 





Fig. 267. — U-shaped incision preliminary to the temporary or permanent resection of the ramus 
of the lower jaw for malignant disease of the tonsil. 

Fig. 268. — The temporary resection of the ramus of the inferior maxilla to expose the fauces 
in the removal of malignant tmnor of the tonsil. 

(e) The jaw bone is sawed through along the line of the periosteal 
incision just in front of the insertion of the masseter muscle. 

(/) The connective-tissue attachments of the ascending ramus of the 
jaw on its inner surface are then carefully dissected from the bone, care 
being exercised to avoid injuring the muscles of mastication. 

(g) The ascending ramus of the jaw is then lifted outward and up- 
ward, thereby exposing the region of the tumor to view (Fig. 268). 

(h) The tumor is then exposed by dissection. The external carot'd 
artery lies externally and posteriorly. 

(i) The tumor should be removed with the knife and scissors, care 
being exercised to avoid opening into the cavity of the mouth until 
the last moment, so as to keep the secretions from entering the wound. 

(j) The ascending ramus of the jaw is then returned to its normal 
position and sutured with wire. 

(/t) The skin is then sutured with horsehair or with Harris' buried 
suture. 

(/) The wound is dressed through the mouth, healing taking place 
by granulation, as after an ordinary tonsillectomy. 



PART III. 
DISEASES OF THE LARYNX. 



CHAPTER XXV. 

INFLAMMATORY DISEASES OF THE LARYNX AND EPIGLOTTIS. 
ACUTE INFECTIOUS EPIGLOTTITIS. 

Synonyms. — ^Angina epiglottic! ea anterior (Michel); acute infectious 
epiglottitis (Theisen). 

The disease is often primary, and is an acute infectious process. 
Clement F. Theisen reports three cases, and gives a most admirable review 
of the literature on the subject. Michel, in 1878, first described an in- 
flammatory process, involving the anterior sufrace of the epiglottis, under 
tliis name. It is usually accompanied by more or less circumscribed 
edema. While the larynx may be somev^hat involved in some cases, 
Theisen claims that true angina epiglottidea occurs quite often as a 
primary, separate, distinct condition. 

Etiology. — In the diffuse type of inflammation the epiglottis may 
become inflamed by an extension from acute tonsillitis, pharyngitis, or 
lingual tonsillitis. In the true primary type its origin is not thus ex- 
plained. In the cases reported by Theisen there was no history of 
coryza, or other acute infectious condition of the upper respiratory tract. 
The larynx was but slightly involved. The ages of the patients were 
thirty-six, forty, and fifty-nine years respectively, one male and two 
females. Hajek's experiments show that the submucosa of the anterior 
surface of the epiglottis is abundant and the mucosa loosely adherent, 
while on the laryngeal surface it is tightly adherent to the cartilage except 
at the nodules, where there is some loose submucous tissue. These 
anatomical facts explain why the edema does not extend to the larynx, 
as one might at first expect it would do. In excessive edema it may, 
however, extend to the larynx by way of the submucous tissue of the 
pharyngo-epiglottic ligament, thence to the aryepiglottic folds. Injury 
to the epiglottis or the neighboring tissue by swallowing foreign baJies 
or irritating substances may cause the condition. Hot drinks, raw 
spirits, or highly spiced liquids may also be regarded as possible predis- 
posing etiological factors. In edema of the fauces due to large doses of 



422 DISEASES OF THE LARYXX 

the iodide of potash the epiglottis may become involved. The infection 
fevers are also liable to give rise to this distressing condition. 
I Perichondritis, carcinoma, and nlcerative conditions dne to syphilis 
or tuberculosis may suddenly become complicated by it. 

Bacteriological examinations made in 2 of Theisen's cases showed 
Streptococcus aureus and pneumococcus in 1, and Staphylococcus albus 
and pneumococcus in the other. The atrium of infection in some 
instances seems to be a traumatic wound, in others it is an extension of 
an acute inflammation from contiguous anatomical parts, and in a third 
class it is a malignant tuberculous or syphilitic ulcer. The chief cause, 
then, is a mixed infection, which may or may not be preceded by a gross 
lesion of the anterior surface of the epiglottis. 

Pathology. — From what has been given under Etiology and Symp- 
tomatology, it may be inferred that the pathology is such as is common 
to acute inflammation of mucous membranes covering loose submucous 
tissue. This consists of inflammatory congestion, exudation, and edema, 
wliich processes, in typical cases, are Hmited to the anterior surface of the 
epiglottis. The bacteriological infection is usually the pneumococcus 
with the Streptococcus aureus or the Staphylococcus albus. 

Symptoms. — The onset is sudden and attended by fever, painful 
deglutition, stiff swollen tongue, and dyspnea, especially upon lying down. 
In one case reported by Theisen the latter symptom was so pronounced 
as to necessitate propping the patient up in bed. 

The febrile symptoms are similar to infectious fevers in general. 

Upon examination the anterior surface of the epiglottis is red and 
swollen, while the adjacent tissues are usually, but little, if at all, involved. 
These symptoms continue with more or less severity for five or six days, 
when they abate in intensity, the epiglottis remaining red and swollen 
a few days longer. 

Diagnosis. — If certain characteristic symptoms are born in mind, 
there need be but little difficulty in arriving at a correct diagnosis. 
These symptoms are: (a) Sudden onset. (b) A febrile movement. 
(c) Redness and swelling limited to the anterior or Ungual surface of 
the epiglottis, (d) More or less painful deglutition. 

Acute angioneurotic edema is unattended by fever, and the edematous 
tissue is pearly gray instead of red. 

It should be differentiated from acute miasmatic epiglottitis, which 
follows exposure to salt marshes, as in hunting for ducks on the mud 
flats of the CaUfornia coast. Arnold has described this condition in 
Burnett's system on the Nose, Throat, and Ear. (See Acute Miasmatic 
I^'pigiottitis.) 

Prognosis. — The prognosis in most cases is good, although deaths 
have been reported by Tompkins, Louis, Gibb, Crisp, and Fredet. 
rr()])('r treatment exerts a favorable influence upon its course. 

Treatment. — Early scarification of the edematous parts gives prompt 
relief in some instances. It should be done freely. Meyjer recommends 
the use of iced ichthyol sprays, which are prepared by putting cracked 
ice into the spray tube containing the ichthyol solution Theisen 



ACUTE CATARRHAL LARYNGITIS 423 

speaks of using a -^ per cent, solution of ichthyol every twenty to thirty 
minutes while the acute symptoms continue, and at longer intervals 
afterward. It is important to give early relief, as the patient may not be 
able to swallow even liquid food until it is done. Calomel and saUnes 
may be given advantageously at the onset. 

The physician should be prepared to do tracheotomy at any moment, 
as suffocative symptoms may suddenly develop. 



MIASMATIC EPIGLOTTITIS. 

Arnold, in Burnett's System, describes an acute inflammatory process 
chiefly involving the epiglottis. It is attended by pronounced edema 
of the epiglottis, painful swallowing (odynophagia), and dyspnea. 

Etiology. — He attributes the cause "to some animal, vegetable, or 
chemical poison in the exhalations of the salt marshes." He describes 
six cases, all men who had returned from hunting ducks on the mud flats 
of the salt marshes on the California coast. It is probable that the cases 
were due to an infection (probably mixed) from some nidus of propaga- 
tion in the marsh country along the coast. Whether the cases should 
stand apart as illustrative of a separate and distinct disease is perhaps 
doubtful. 

Symptoms. — Epiglottic edema and inflammation may be pronounced, 
the adjacent structures also being somewhat involved. There is odyno- 
phagia and dyspnea. In one case the suffocative symptoms became so 
alarming that tracheotomy was performed. Pyrexia is more or less 
marked. 

MALARIAL EPIGLOTTITIS AND LARYNGITIS. 

There appears to be a type of laryngitis due to malarial poisoning. 
The adjacent anatomical structures, including the epiglottis, are some- 
what red and slightly swollen. There is pyrexia of an intermittent 
type, as one might expect in malarial poisoning. Hoarseness and 
dyspnea are prominent symptoms. 

The broinide of quinine should be administered in full doses in malarial 
poisoning attended by laryngeal symptoms. Iced sprays of a 0.5 per 
cent, solution of ichthyol will hasten a favorable issue, as there is probably 
also some coccus infection in these cases. 



ACUTE CATARRHAL LARYNGITIS. 

Synonyms. — Catarrhal laryngitis; acute catarrh of the larynx; 
simple laryngitis; laryngitis catarrhalis acuta. 

Acute catarrhal laryngitis is an acute catarrhal inflainuiation of llu 
laryngeal mucosa and of the vocal cords. It is charactcri/erl by lioaise- 
ness or aphonia, and pain upon phonation. 



424 nrSEASES OF THE LARYXX 

Etiology. — TIk' etiology of acute catarrhal laryngitis may be studied 
under: (1) Systemic disturbances and diseases; (2) preexisting diseases 
of the ui)per respiratory tract; (3) hygienic conditions and environment; 
(4) traumatism; {')) age; ((i) cHmate; (7) idiopathic causes. 

1. Systemic Disturbances. — Systemic disturbances, as "catching cold," 
arthritis, the eruptive specific fevers, syphilis, and tuberculosis, play an 
important role in the causation of catarrhal inflammations of the larynx. 
" Catching cold" is a complex process difficult to explain, but in general 
it may l)e said to include an imbalance of the vasomotor nerves, whereby 
the capillary vessels are erratically controlled. Increased vascularity, or 
congestion, is thus a common disturbance. According to Woakes and 
J. A. Stucky, the phenomena of "catching cold" are due to digestive 
disturbances and the end results therefrom, e. g., toxic products in the 
circulation, which irritate the vasomotor nerves, thus establishing a 
predisposition to "catching cold." Clinical observation seems to support 
the above theory in so far that acute laryngitis quite often follows or 
accompanies digestive disorders. Arthritis also seems to have a causa- 
tive relation to laryngitis, and, inasmuch as it is an inflammatory dis- 
ease of infectious origin, it is easy to appreciate the fact that certain 
toxins are in the circulation and affect the tonicity of the vasomotor sys- 
tem, very much as in acute coryza, or "catching cold." The toxins of 
syphilis and tuberculosis likewise irritate and disturb the vocal apparatus. 
In addition, the pathological lesions are often localized in the larynx, and 
are specific in character. The exanthematous or eruptive fevers are 
often accompanied or followed by laryngitis. The specific microorgan- 
isms peculiar to these diseases are especially profuse in the upper 
respiratory tract; indeed, they probably gain entrance to the system 
through the mucosa of the nose and throat when the resistance is 
lowered, especially in the tonsil and adenoid; hence, the mucosa of the 
larynx is subjected to the direct irritation from their presence, as well as 
to the toxins in the blood. 

2. Preexisting Diseases. — Preexisting diseases of the upper respiratory 
tract are important predisposing etiological factors in laryngitis. This 
is especially true in reference to sinus diseases, nasal stenosis, and infec- 
tious inflammations of the tonsils. It may be stated as an axiom that 
inflammatory processes in o}ie part of the upper respiratory trad tend to 
extend to contiguous parts. This is in part explained by the extension 
by continuity of tissue, and in part by the simultaneous exposure of the 
various structures to microbicand toxic irritation. The most vulnerable 
area is first affected, the contiguous parts later becoming involved. The 
tendency is for the inflannnatory process to extend downward rather than 
nj)vvard, probably because the flow of lymph streams is in that direction. 
Jt is true, however, that there is a marked hesitancy in the downward 
extension from the nose to the larynx. This is explained by the differ- 
ence in the character of the epithelium covering the mesopharynx. 
Nearly the whole of the mucosa of the upper respiratory tract, except 
the mesopharynx, is covered with ciliated columnar epitheliuin, whereas 
the mes pharynx is covered with squamous epithelium. Inflannnatory 



J 



ACUTE CATARRHAL LARYNGITIS ' 425 

processes do not readily extend from one kind of tissue to another, hence 
the hesitancy. If, however, the nasal inflammation is severe and pro- 
longed, or often repeated, the inflammation finally reaches the larynx. 
Indeed, the "dropping" into the hypopharynx often leads to catarrhal 
inflammation of the larynx by lowering the resistance of the laryngeal 
mucosa, which subsequently becomes infected. In sphenoidal and 
posterior ethmoidal sinuitis the secretion and the exudate are discharged 
into the epipharynx and drop or trickle down the walls of the meso- 
pharynx on the upper surface of the larynx, irritating the mucosa. The 
mucous membrane of the larynx becomes lowered in resistance, and 
infection and inflammation follow. In obstructive deflections of the 
septum the respiratory functions of the nose, namely, moistening, 
warming, and filtering the air, are lost. The pharyngeal and the laryn- 
geal mucosa are, therefore, subjected to an air that is irritating to it. 
This in time causes lowered resistance, infection, and laryngitis. 

We may say, then, in a general way, that diseases of the respiratory 
tract above the larynx often predispose to catarrhal inflammations of the 
larynx by (a) extension by continuity of tissue; (b) extension by con- 
tiguity of tissue; (c) extension by lymphatic communication; [d) by 
irritation and lowered resistance from nasal and accessory sinus secre- 
tions; (e) simultaneous exposure of the entire upper respiratory tract to 
micro bic infection; and (/) by the irritation from the toxins evolved by 
the bacteria in the nose, the accessory sinuses, the epipharynx, and the 
tonsils. The chief barrier to the downward ' inflammatory extension is 
in the squamous epithelium of the mesopharynx. 

3. Hygienic Conditions and Environment. — Under hygienic conditions 
and environment as causative agents in catarrhal laryngitis are included 
(a) the inhalation of noxious gases; (6) poor ventilation; (c) undue exposure 
of feet and body; (d) improper bathing; and (e) the abuse of the voice. 

The inhalation of noxious gases, as in chemical laboratories, factories, 
etc., may cause laryngitis by direct irritation, or it may lower the resist- 
ance of the tissues and predispose to infection. Poor ventilation likewise 
causes laryngitis, though not by direct irritation. In the latter instance 
the vital energy is lowered by breathing impure air. Then, too, the 
oxygen in the air is diminished in quantity. The vitiated atmosphere 
irritates the endothelial lining of the air vesicles, and thereby causes 
changes which interfere with the absorption of oxygen into the blood and 
the expulsion of carbonic acid gas from the blood. These factors com- 
bine to deprive the patient of the normal amount of oxygen, and lead to 
an oversupply of carbonic acid gas. The processes of metabolism are thus 
deranged, and toxemia results. The vital energies are lowered, and the 
patient is in prime condition to be aft'ected by bacterial infection and 
inflammation. Undue exposure of the body, especially the feet, is a 
prolific exciting cause of laryngeal inflammation. The large vessels of 
the feet give ofl^ large quantities of heat when the soles of the feet are 
insufficiently protected from the cold ground. When this occurs there 
is a shock to the terminal vascular system, which causes an iml)alanceof 
the physiological functions of the mor(> delicate structures of the body. 



420 DISEASES OF THE LARYXX 

The larynx in some cases is the vnhierable point, and reacts in the form 
of a catarrhal laryngitis. The question of clothing is discussed more 
fully under the etiology of the nasal inflammations. Suffice it to say, 
therefore, in this connection that tliere is danger in an excessive amount 
of clothing, as well as in too little. One accustomed to living in an open, 
poorly constructed residence, and changing to a well-built city residence, 
which is overheatetl and poorly ventilated, is especially subject to 
catarrhal inflammations of the upper air passages. 

Bathing, when judiciously practised, is a healthful and invigorating 
procedure. When, on the contrary, it is injudiciously practised, it may 
cause considerable miscliief to the upper respiratory tract. What is good 
practice for one may be bad for another. Hard-and-fast rules cannot be 
laid down. For some a cold plunge or shower bath after a warm bath 
is invigorating, whilst for others it throw\s them into a mild state of shock 
from wliich they do not quickly react. A Turkish bath is often a harmful 
procedure unless the bather remains for some hours in rooms of gradu- 
ally diminishing temperature. Hyperemia of the superficial vessels is 
induced, and if the bather goes out into the open air before the circu- 
latory balance is restored, he is liable to "catch cold." The abuse 
of the vocal apparatus in singing and speaking disturbs the circulatory 
poise, and by mechanical irritation excites inflammation of the cords 
and the raucous membrane. For a further consideration the reader is 
referred to the chapter on the Speaking and Singing Voice. 

Pathology. — The liistological changes in acute catarrhal laryngitis 
ar(^ the same as in inflammations of the mucosa of other portions of the 
upper respiratory tract. The peripheral vessels are congested and the 
tissues are infiltrated with round cells and leukocytes. If the inflamma- 
tion runs a short course the infiltration disappears, leaving little or no 
trace of its occurrence. Should the inflammation be phlegmonous, the 
tissues become edematous and the surface epithelium eroded in patches. 
The secretions at first are thin and scanty, later becoming heavier and 
more profuse. In severe cases the secretions may become purulent and 
streaked with blood from the superficial follicular ^ulcers. The path- 
ology of laryngitis secondary to the exanthematous fevers does not differ 
from ordinary laryngitis except as to the microorganisms causing the 
disease and the greater tendency to phlegmonous inflammation. The 
greatest swelling in laryngitis is naturally in the most lax parts, namely, 
in the ventricles, though the true cords are sometimes red and swollen 
like sausages. In children the swelling is sometimes below the cords, and 
is a source of extreme danger. 

Symptoms. Objective Symptoms. — The objective symptoms embrace 
the changed ap{)ea ranee of the cords, the mucosa, the secretions, the 
exudate, and pathogenic bacteria. With the laryngeal mirror and 
reflected light an inverted image of the larynx is shown. The mucosa 
is red and more or less swollen from hyperemia and infiltration, or 
edema, according to the virulency of the inflammatory process. The 
cords are pinkish red, or even as red as the mucosa. Sometimes ecchy- 
motic sj)ots of extravasated blocMl may be seen on their up])er surfaces. 



J 



ACUTE CATARRHAL LARYNGITIS 427 

or free borders. The secretions are at first thin and scanty; later they 
become thick, semi trans hicent, or opaque, according to the amount of 
lymphocytes thrown out. The secretions have a tendency to accumu- 
late at the anterior commissure and to some extent along the cords. 
They appear as opaque plugs rather than as thin, diffused, glairy masses. 

When follicular ulcers are present the denuded areas appear as slightly 
roughened red spots, or, if covered with secretions, as whitish opaque ones. 
In some cases there is a cloudy swelhng of the epithelium in isolated 
areas. These areas are the beginnings of ulcerations. They appear 
as slightly elevated patches, with a grayish semitranslucent covering. 
Hemorrhages may occur at the commissure of the cords, or on the ven- 
tricular bands. At first the site of the hemorrhage is red, later almost 
black. When the inflammation is severe the venous flow may be blocked 
so that the parts are edematous. This condition is sometimes termed 
hydrops laryngis. The temperature varies from a slight elevation to 
one of several degrees, according to the severity of the inflammation and 
the virulency of the microorganisms contributing to the phenomena. 
The paralysis or paresis of the intrinsic muscles of the larynx, which 
sometimes occurs, may be due to a neurosis, though it is more often due 
to a mechanical interference by infiltration and degeneration of the 
muscles and the tissues immediately surrounding the nerve endings. 

Subjective Symptoms. — The subjective symptoms have reference to 
the changes in voice and respiration, and to pain and cough. The voice 
may be hoarse in any degree, or aphonia may be present. The hoarse- 
ness is due to the swelling and infiltration of the cords and adjacent 
mucous membrane, and to the paresis or paralysis of the muscles. The 
respiratory effort may be sHghtly labored, on account of the diminished 
lumen of the chink of the glottis, or to the paresis or paralysis of the 
abductor muscles. 

In those cases complicated by excessive edema the respiration may 
be labored because of the edematous swelling. The respiration is 
shallow on account of the cough excited by deep breathing. The char- 
acter of the cough depends largely upon the individual, though it bears 
some relationship to the stage and intensity of the disease. In the early 
stage it is usually soft and husky, whereas later it is more heavy and 
harsh. In those cases in which there is extensive infiltration and edema 
it is spasmodic, hoarse, and wheezy, with but little tonal quality. If the 
inflammation is limited to the interarytenoid space, hoarseness may be 
absent. 

Prognosis. — The prognosis depends somewhat upon the primary 
cause, that is, whether it is due to a chronic constitutional disease, like 
syphilis, or to a simple exposiu-e which causes temporary lowered resist- 
ance of the tissues. If due to the former, the prognosis as to the voice is 
l)ad. If to the latter, it is good. If the attack is primary, it is good. If it 
is one of a series of acute attacks, the chances are in favor of its recurrence, 
as the etiology is evidently a fixed factor. Again, the prognosis depends 
largely upon the character of treatment administered. It is obvious 
that if the cause is a nasal obstruction from septal malformation, the 



42,S niSKASKS OF THE L ART XX 

prognosis will depend u})on the treatment institnted. If dne to nasal 
disease, and sprays, lozenges, and medicated nebnUp are nsed, the prog- 
nosis is bad. If the nasal disease is correctwl by snitable treatment or an 
operation, the ])rognosis is good. Finally, an(l perhaps of more impor- 
tance than all other considerations, the prognosis depends npon whether 
complete rest of the vocal apparatus is observed. If this is done for 
from three to ten days, the simple catarrhal inflammation will subside, 
leaving tlie voice clear. 

Treatment. — The successful treatment of the immediate symptoms 
consists largely in giving the voice complete rest. Without this all other 
methods are usually futile and the inflammation runs its full course. 
Confine the patient to his room, the temperature of which should be 
maintained at from 67° to 70°. The atmosphere should be sur- 
charged with steam from boihng water to which turpentine and creosote 
have been added. Keep the bowels open with calomel and salines. 
Place the feet in a hot mustard bath, after which hot lemonade should 
be administered. Then wrap the patient in a woollen blanket and put 
him to bed. Still further relaxation may be induced by the administration 
of effervescing tablets of pilocarpine, y^^ of a grain. One tablet should 
be given every hour until three or four are taken. The inhalation of 
steam impregnated with the compound tincture of benzoin, one teaspoon- 
ful to the pint of boiling water, affords relief, and should be used every 
two to three hours. Kyle recommends the following prescription: 

I^.— Acidi nitrici TTl iij (0.18) 

Tr. opii deodorati rT\ iij (0.18) 

Cocaini phenati gr. Vio (0.006) M. 

Sig. — Give every liour until three or four doses are taken. 

An ice-bag applied to the neck exerts a favorable influence in the 
phlegmonous variety, though it should not be applied longer than a few 
minutes at a time. A compress of cold water applied over the larynx 
l)eneath a flannel bandage also relieves the laryngitis, as it induces hypere- 
mia and leukocytosis just as when heat is applied. It is an open question 
as to whether the relief is due to the compress per se or to the constriction 
of the bandage, according to Bier's principle. The constriction also 
increases the local leukocytosis and thus frees the inflamed tissues of 
the infectious agents and dead tissue cells. Whether the good results are 
due to the water compress or to the constriction the effects are favorable. 
An oily spray of menthol, 1 to 2 grs. to the ounce, is a pleasant appli- 
cation, affording temporary relief. Its frequent use, however, irritates 
the mucous membrane, hence it should not be used oftener than twice 

In severe cases in which there is considerable obstruction to the breath- 
ing it may be necessary to puncture the swollen laryngeal mucosa with 
a laryngeal knife (Fig. 269). The serous fluid in the edematous 
membrane is thus let out without serious damage to the parts, and 
in addition the reaction of inflammation is promoted and the bacteria 
more rapidly destroyed. In extreme cases it may become necessary to 
intubate or to ])erfonn trach(>otomy. (S(>e Intnl)ati<)n and Tracheotomy.) 



ACUTE LARYNGITIS IN CHILDREN 429 

In infants the clanger in acute laryngitis is much greater than in 
adults, on account of the relatively smaller and absolutely occluded 
chink of the glottis. Then, too, the mucosa is much more richly supplied 
with lymphatic and bloodvessels and is more loosely attached to the 
deeper structures. For these reasons the mucosa is more prone to 
become swollen or ederriatous and cause suffocation. A fatal issue 
is possible. 

For the relief of the cough, codeine sulphate, gr. yV to \, may be 
administered every three hours until relief is afforded. 



Laryngeal lancet. 

In the later stage (after the second week) it may be advisable to touch 
the inflamed cords with the soKd stick of nitrate of silver. This should 
be done but once. In the milder cases the larynx may be painted with a 
2 to 4 per cent, solution of the nitrate of silver. 

The principles of treatment are: (a) Absolute rest of the voice, the 
patient remaining in a warm room containing steam vapor. (6) Free 
purgation to promote the elimination of the toxins and ferments, and 
(c) relaxation of the peripheral vessels of the body by the administration 
of pilocarpine and hot drinks, {d) Diaphoresis, aided by wrapping in 
warm blankets, {e) The relief of cough by the use of codeine or other 
sedatives. (/) Scarification, intubation, or tracheotomy in threatened 
suffocation, {g) Caustic and astringent applications in the late stage. 



ACUTE LARYNGITIS IN CHILDREN. 

Synonyms. — Pseud ocroup; false croup; Miller's asthma; laryngitis 
stridulosa. 

In children acute laryngitis is often characterized by a spasmodic, 
croupy, or barking cough and suffocative fits. The subjective symptoms 
are quite like those of tracheal diphtheria, hence the name pseudocroup. 
Histologically it is a true catarrhal process. 

Etiology. — The etiology of catarrhal laryngitis in children is in general 
like that occurring in adults, though many of the exciting causes are 
absent, on account of the different habits of the child or infant. The 
special etiology in children consists of the presence of adenoids and the 
epipharyngitis accompanying them, and in the different anatomical 
construction of the larynx. In children the chink of the glottis is both 



-130 DISEASES OF THE LARYXX 

relatively and absolutely smaller, the lymphatic and vascular structures 
are more abundant, and the mucosa is more loosely attached to the 
underlying tissues. All these factors predispose the larynx of the child 
to attacks of laryngitis; they also render the disease a much more serious 
one on account of the suffocative phenomena. In addition to the fore- 
going facts should be added the greater susceptibility of children on 
account of the unstable condition of the nervous system and glandular 
tissues. A moderate amount of swelling of the mucosa, either above or 
below the true cords, to which is added an irritation of the terminal motor 
nerve filaments, is often sufficient to bring on severe and alarming fits 
of dyspnea and suffocation, even to the point of death. 

The disease in children may be divided into two varieties, namely, 
(a) acute supraglottic laryngitis, and (6) subglottic laryngitis, or Miller's 
asthma. 

The symptoms of acute supraglottic laryngitis more nearly resemble 
the adult type, though in many cases the spasmodic suffocative fits are 
present on account of the extreme swelling and edema of the mucosa 
and the paresis of the abductor muscles. 

The subglottic variety is more dangerous on account of the swollen 
mucous membrane being confined at its circumference by the cartila- 
ginous rings of the trachea. The swelling must, perforce, encroach 
upon the lumen of the trachea, and close the breathway. 

Symptoms. — The objective symptoms are about the same as in the 
adult. (See Acute Catarrhal Laryngitis.) The subjective symptoms are 
somewhat different on account of the greater swelling and the smaller 
lumen of the chink of the glottis. The prodromal symptoms are those 
of cold, the respiration becoming embarrassed toward evening. A dry 
cough appears before bedtime, but is not severe enough to prevent 
sleep. Toward midnight the child is suddenly seized with a laryngeal 
spasm and embarrassed breathing. The cough is loud and harsh. 
Inspiration is difficult and accompanied by stridor. The child becomes 
cyanotic, and death seems imminent. After a few minutes the symp- 
toms disappear and the child falls asleep. The following night, and 
perhaps for two nights, the attack returns with diminishing severity, 
until after a few days all signs of the disease disappear. In these cases 
there is a true spasm of the muscles of the larynx, probably due to the 
natural hypersensitiveness of the nervous system in infants and growing 
children. In the subglottic variety the swollen mucosa beneath the true 
cords may be seen through the chink of the glottis as beefy-red bands. 
These cases closely resemble tracheal diphtheria in their subjective 
symptoms, though an inspection of the larynx and a microscopic examina- 
tion of the secretion and exudate will clear the diagnosis. 

Diagnosis. — Acute laryngitis in children should be differentiated 
from dij)htheria, pseudomembranous croup, laryngismus stridulus, 
foreign Ixxlies, and perichondritis. 

Diphtheria is characterized objectively by a membranous deposit, 
which may be seen upon laryngoscopic examination. It may be either 
on the laryngeal mucosa or in the trachea, or both. Cultures show the 



ACUTE LARYNGITIS IN CHILDREN 431 

diphtheria bacilli. In acute laryngitis there is an absence of the false 
membrane and the bacilli, while the mucosa is greatly swollen and 
reddened. If it is of the subglottic variety, the swollen red mucous 
membrane may appear as round, reddened cords, parallel with and 
below the true cords. The temperature is usually higher in acute 
laryngitis in children than in true diphtheria, while the prostration is not 
so pronounced. 

Pseudomembranous croup has a sudden onset, while acute laryngitis 
begins with the symptoms of a cold. In pseudomembranous croup the 
suffocative symptoms make steady progress with little or no remission. 
The laryngoscopic image in pseudomembranous croup shows the pres- 
ence of the membrane, whereas in acute laryngitis the mucosa is red 
and swollen. The Klebs-Loeffler baciUi are absent in both diseases. 
The systemic disturbance is less marked and not so severe. There are 
no nocturnal exacerbations, as there are in acute laryngitis with the 
laryngismus stridulus phenomena superimposed. 

Foreign bodies in the larynx are differentiated by the history of the 
accident, the sudden onset of the suffocative symptoms with no prodromal 
history, and the image of the foreign body in the larynx. 

Perichondritis of the cricoid cartilage is characterized by irregular 
nodules in this region and the chronicity of the case. It is usually 
associated with a tuberculous process in the lungs. 

Prognosis. — The prognosis of acute laryngitis in children is favorable 
in most cases, though a fatal termination is possible, especially in the 
subglottic variety. The disease runs its course in from six to twelve 
days. 

Treatment. — Prophylactic measures should be instituted in those 
cases in wliich there is a history of recurrent attacks. A child subject 
to laryngitis with pulmonary complications, as bronchitis, should have 
the tone of the system built up by daily cold sponge baths, followed 
by brisk rubbing with a towel until the skin glows. During the summer 
he should be kept in the open air and sunshine as much as possible. At 
night the room should be well ventilated. The food should be nutritious, 
easily digested, and liberal in quantity. The clothing should be of Hnen 
mesh next to the skin all the year round. In the winter light woollen 
underwear should be worn over the linen mesh. If there are adenoids 
or diseased tonsils, they should be removed. If suppurative rhinitis is 
present it should receive appropriate treatment. All other ailments 
should be corrected as nearly as possible. In short, all disorders should 
be attended to and a healthful vigor established as soon as possible. In 
this way laryngeal inflammation may be prevented. 

In the beginning of the acute attack the bowels should be unloaded 
by the administration of broken doses of calomel, followed by a saline 
cathartic. During the acute stage the child should be confined in a 
room ke})t at a temperature of about 70°, and the atmospliere sur- 
charged with steam. The feet should be placed in hot mustard-water for 
fifteen minutes, after which the patient should be wrapped in a woollen 
blanket and put to bed, to encourage diaphoresis. If there is much 



432 DISEASES OF THE LARYXX 

mucu.s in the throat and trachea, an emetic should be administered. If 
the secretions are scanty or tenacious, the inhalation of menthol vapor 
from a nebulizer, or from the crystals in boiling water, stimulates the 
secretions and gives marked relief. 

External application of an ice-bag or a cold compress to the neck often 
affords relief. The ice-bag should be covered with woollen cloth and left 
in position for only a few minutes at a time. Counterirritation to the 
neck with iodine, camphorated oil, kerosene, etc., is used to relieve the 
swelling when it is pronounced, and to promote the reaction of inflam- 
mation. 

In the later stage paregoric, Dover's powder, codeine, etc., may be 
administered in small doses to relieve the cough. If the secretions are 
heavy and accumulate in the larynx and trachea, an emetic should be 
given to clear it away. 

Surgical interference may be necessary when the symptoms become 
alarming. If, upon larvngoscopic examination, the mucous membrane 
above the cords is found to be greatly swollen, it should be punctured 
with a laryngeal lancet (Fig. 269). Or if the cyanosis is marked and 
does not yield to other methods of treatment, intubation or tracheotomy 
should be performed to save the child's life. (See Intubation and Trache- 
otomy.) These extreme measures are rarely necessary, but it is well to 
recognize that in children this disease is sometimes attended by death 
unless the breathing is maintained by medicinal, hygienic, or surgical 
interference. 



ACUTE PHLEGMONOUS LARYNGITIS. 

Definition. — Acute phlegmonous laryngitis is a catarrhal inflamma- 
tion of the laryngeal mucosa, to which is added an edematous effusion 
which runs an inflammatory course, for example, serous, seropurident, 
and purulent stages. The mucous membrane becomes undermined 
with purulent secretion. 

Etiology. — The causes of this variety of laryngitis are al)out the same 
as in acute catarrhal laryngitis, except that the infection is more virulent. 
The disease is common among hospital attendants, on account of their 
exposure to erysipelas and other infectious diseases. It is rarely primary, 
but is usually secondary to some other infectious disease. It occurs 
most frecjuently between the twentieth and the fortieth years of life. 

Pathology. — The pathology is the same as in inflammatory edema 
of mucous membranes elsewhere in the body. The mucous and sub- 
mucous tissue are infiltrated with round cells, and there is an eft'usion 
of serum and pus corpuscles. On account of the loose texture of the 
mucous meml^rane in the aryepiglottic region, the ventricular bands, and 
the subglottic region, there is a great swelling and respiratory obstruction, 
as in acute laryngitis of children. There is at first a vascular engorge- 
ment, followed by a serous effusion. Later the effusion takes on a 
seropurulent and finally a purulent character. General sepsis may 
follow, and prove a serious complication. 



MEMBRANOUS LARYNGITIS 433 

Symptoms. — The symptoms during the first twenty-four hours are 
about the same as in the acute catarrhal variety. A chill and elevation 
of temperature are often the initial symptoms. The symptoms gradually 
grow worse, and dyspnea often occurs within the first twenty-four hours. 
Pain and soreness are usually complained of. Cough may or may not 
be present. 

Objectively, the laryngoscopic mirror shows the mucous membrane 
to be red, tense, and glassy, with three rounded, swollen masses above 
the cliink of the glottis. If the subglottic region is involved, the swollen 
membrane may be seen protecting from below the true cords. 

Prognosis. — ^The prognosis is grave on account of the rapid develop- 
ment and the septic infection. If, however, the dyspnea persists longer 
than thirty-six hours without severe sepsis or other untoward compHca- 
tion, the case will probably end in spontaneous resolution. The cases 
should be watched closely during the first tliirty-six hours. 

Treatment. — ^The treatment consists in local depletion with ice-bags, 
followed by the use of leeches and scarification. The ice-bag should be 
applied for forty minutes, after which three or four leeches, two on either 
side, should be applied to the skin over the larynx. The cold reduces 
the swelling and thus establishes a more rapid flow of blood through the 
inflamed tissues, and the leeches bring about an increased leukocytosis. 
The cellular resistance is increased by the greater amount of blood 
flowing through the tissues. The various reactions produced by the cold 
and leeches establish ideal conditions for the destruction of the infec- 
tious microorganisms. The administration of calomel and salines 
promote the elimination of the toxins. The atmosphere of the room 
should be kept surcharged with steam. If scarification is resorted to, 
the laryngeal lancet (Fig. 269) should be used by the aid of the laryngeal 
mirror and reflected light, or by direct laryngoscopy. The swollen 
mucous membrane should be repeatedly punctured rather than scari- 
fied, as the damage to the parts is less and the relief is equally great. 
The cliief benefit of scarification is in the increased leukocytosis excited 
by it. It may be necessary to resort to tracheotomy should suffocation 
become imminent. If sepsis is a pronounced compHcation, the adminis- 
tration of alcohoHc beverages and strychnine is indicated to support 
the system. 

MEMBRANOUS LARYNGITIS. 

Synonjmis. — Croup; croupous laryngitis; hautige briiune; diph- 
theritic laryngitis; pseudomembranous croup; idiopathic membranous 
croup. 

Definition. — Membranous laryngitis is characterized by an inflamma- 
tion of the larynx, attended by the formation of a false membrane of non- 
diphtheritic origin. Opinions differ as to the unity or duality of this 
disease and true diphtheria. The evidence, however, seems to show 
that they are two diseases, the latter being due to an infection from the 
Klebs-Loeffler bacillus, while the former (croup) is due to an infection 
28 



434 1)1 si: ASKS OF THE LARYXX 

from otluT inicroori^anisms, usually the cocci, or to a caustic irritant. 
When due to the latter the membrane is not of microhic origin, though it 
may become so secondarily. Under the microscope it presents the 
same ap[)earance as that due to cocci. 

Etiology. — The causes of membranous laryngitis are microbic, 
chemical, and mechanical irritants. Exposure to damp and cold, and 
neuroses are predisposing causes in young children. The cases of 
microbic origin usually follow or attend scarlet fever, measles, smallpox, 
etc. Exposure to damp and cold seems to precipitate attacks by lower- 
ing the vital resistance, and thus estabhshing a suitable soil for the 
bacterial growth. Chemical and mechanical irritants seem to cause the 
membranous formation without bacterial influence, although this is 
not certain. Some children seem to have a predisposition to a mem- 
branous inflammation of the larynx, though in these cases I suspect 
adenoids and epipharyngitis may be the explanation of the susceptibility. 
It is essentially a disease of young childhood, occurring chiefly between 
the ages of two and eight. It is most prevalent in the pneumonia or 
winter season. 

Pathology. — The membrane is in two layers, a superficial or epithelial, 
antl a deeper or fibrous layer. It is comparatively loosely attached to 
the mucous membrane, whereas in diphtheria it is firmly attached. 
The epithelial layer of the mucosa is rapidly proliferated, and enters into 
the composition of the pseud omembrane. The mucous membrane is 
hyperemic and red, and in places is denufled of its epithelium. The 
bacteria causing the inflammation are chiefly of the coccus group, for 
example, pneumococcus, streptococcus, and staphylococcus, though 
other bacteria, as the spirillum and the bacillus pyocyaneus are found 
and probably contribute to the etiology. The membrane is not grayish- 
white, as in diphtheria, but is yellow^ish and of a soft, friable consistency. 
It is more easily removed and does not leave an ulcerated or bleeding 
surface as in diphtheria. 

Symptoms. — The laryngoscope shows a free fauces, a coated tongue, 
and hyperemia of the fauces and the larynx. The membranous forma- 
tion appears on the aryepiglottic fold, on the ventricles, and occasionally 
on the vocal cords. It is usually primary in the larynx, though it may 
originate in the fauces and pharynx, and spread to the larynx. The 
laryngoscopic image, therefore, shows a yellowish, frialile, dirty mem- 
brane in one or more of these regions. The temperature rapidly rises 
to 102° or 103°. 

The onset of the disease may be the same as in acute catarrhal laryn- 
gitis, but in the course of an hour or two a loud, brassy cough develops, 
which steadily increases until toward midnight, when it reaches its 
climax. There is loss of appetite, and the patient complains of thirst. 
The pulse is full and the skin is hot and dry. Deglutition becomes 
painful. The cough, at first infrecjuent, becomes more and more frequent, 
and is finally followed by laryngeal spasm. Great dyspnea then comes 
on, and the child , in his endeavors to cough out the obstructing membrane, 
clutches at his throat and tosses about in his bed. These symptoms 



MEMBRANOUS LARYNGITIS 435 

increase in severity as the membrane is formed in the larynx^ until the 
voice is aphonic (silent croup) and the inspiration through the narrowed 
glottis gives rise to a peculiar crowing sound. The next morning the 
symptoms are lessened in severity, only to be increased again in the 
evening. Sometimes the cHmax is delayed until the third night. The 
disease is progressive, whereas in laryngids the obstructive symptoms 
are spasmodic and are not steadily progressive. In case of marked 
glottic obstruction the inspiratory and expiratory dyspnea and asphyxia 
may necessitate intubation or tracheotomy. 

If the dyspnea continues, the pulse becomes weak, the temperature 
falls, and the general strength rapidly ebbs away on account of the 
diminished oxygenation of the blood and the increased amount of carbon 
dioxide in the blood. When the membrane is thick in the region of the 
soft palate there may be a regurgitation of fluid food through the nose. 
This is not due to paresis of the palatal muscles, as in true diphtheria, but 
to the mechanical interference by the false membrane with the action 
of the muscles. 

Laryngismus stridulus sometimes appears in the course of the disease, 
and is to be regarded as a neurotic phenomenon. 

Diagnosis. — Membranous croup resembles in some respects spasmodic 
laryngitis, diphtheria, laryngismus stridulus, and retropharyngeal abscess. 

Prognosis. — The prognosis is grave, some authors reporting from 
50 to 60 per cent, of deaths, while others claim as low as 10 per cent. 
This discrepancy in the reported death rate is probably due to the differ- 
ence in the diagnosis. Those reporting a death rate of 50 to 60 per cent, 
probably include cases of true diphtheria. The prognosis is grave in 
inverse ratio to the age of the patients. The younger the patient the 
more serious is the prognosis. In adults the danger is greatly diminished, 
as the lumen of the larynx is relatively and actually greater, and the 
mucous membrane is more firmly attached. 

In spasmodic laryngitis there is a catarrhal inflammation with spasms 
of the laryngeal muscles, which cause suffocative symptoms. They 
disappear, however, in a few minutes and the child rests comfortably. In 
membranous croup the suffocative symptoms come on gradually and 
disappear as gradually. 

In diphtheria the temperature does not rise so high or so rapidly. 
The chief diagnostic points, however, are the culture of the Klebs- 
Loeffler bacilli and the ashen-gray and firmly adherent pseudomembrane. 
After its removal the mucous membrane is ulcerated and bleeding, 
whereas in membranous croup it is smooth and does not bleed. 

Laryngismus stridulus is a neurosis and not an inflammatory disease, 
hence the laryngoscopic examination shows the absence of inflammation. 
Tlicn, too, there is a history of a healthy child who suddenly has a suffoca- 
tion fit. In membranous crouj) there is a history of inflammation and 
progressive dyspnea. 

Retropharyngeal abscess may simulate membranous laryngitis in its 
sutt'ocative symptoms; otherwise there is little similarity. An examina- 
tion of the throat reveals a fluctuating tumor on the posterior wall of 



436 DISEASES OF THE LARYNX 

the hypopharynx, whereas in membranous laryngitis the tumefaction 
is witliin the laryngeal zone. 

Complications. — ^Membranous laryngitis may become complicated 
with rapid edema of the bronchial mucous membrane or with cardiac 
infection. In either event the case becomes one of great gravity. 

Treatment. — The treatment consists in the administration of broken 
doses of calomel until free catharsis is produced, and in the inhalation 
of steam vapor charged with lime and turpentine. The child should be 
put into a tent-bed and a piece of lime the size of two fists placed in a 
bucket of water, to which has been added a tablespoonful of spirit of 
turpentine. The tent-bed is thus filled with the vapor, which is inhaled 
by the child. The lime and turpentine seem to aid in loosening and 
expelling the false membrane. The steam-tent seances should last 
about fifteen minutes, and should be repeated every four or five hours. 
The efficiency of the steam-tent batlis is increased by the administration 
of ipecacuanha ^^^ne or powder, which is a non-depressing emetic. 

Calomel fumigations, as advocated by Corlin, have proved an efficient 
method of treatment. He recommends the administration of one or 
two grains of calomel before the fumigations begin. The patient 
should then be placed in a completely closed tent-bed. It requires 
about ten minutes to volatilize the calomel, and the patient should be 
exposed to the fumes in the closed tent for about fifteen minutes. It is 
recommended that fifteen grains be volatilized every two hours for two 
days and nights, after which the intervals should be prolonged to tlu-ee 
hours on the third day, four hours on the fourth day, and three times 
daily thereafter as long as indicated. Pure calomel thus used does not 
produce ptyalism, though anemia may occur and should be combated 
bv the administration of iron. 



EDEMA OF THE LARYNX. 

Synonym.— Edema glottidis. 

Edema of the larynx is an inflammatory process attended by an edema- 
tous infiltration of the loose submucous tissue of the larynx which is due 
to a more serious general disease of the heart, kidneys, or the liver, though 
it may be caused by local conditions. 

Etiology. — The local causes are mainly traumatic from the injudicious 
use of caustics, laryngeal injections of creosote in tuberculous inflamma- 
tions, operations, foreign bodies in the supraglottic region of the larynx, 
the swallowing of hot liquids and the inhalation of hot steam, or the 
inspiration of alcoholic or other irritating liquids into the larynx. The 
prolonged or violent use of the voice, as in shouting, may bring on edema 
of the larynx. Local diseases of the larynx, as tuberculosis, syphilis, 
abscesses, neoplasms, perichondritis, and peritonsillitis may also cause it. 
Abscess of the larynx may be accompanied by a non-inflammatory edema. 

The constitutional causes of simple edema of the larynx are Bright's 
disease, diabetes, valvular kvsions of the heart, sclerosis of the liver, and 
Ludwig's angina. In the latter disease there is a neurotic paresis of the 



ABSCESS OF THE LARYNX 437 

bloodvessels of the neck, which causes engorgement and edema. Certain 
drugs, as the iodide of potassium and the fumes of ammonia and 
bromine, may cause it. 

Pathology. — There is an effusion of clear serum into the laryngeal 
submucous tissue, producing swelKng of the aryepiglottic folds and of the 
anterior and superior parts of the epiglottis. Sometimes the loose sub- 
glottic tissue becomes edematous. In associated ulcerative processes 
the serous infiltration may be seropurulent. 

Symptoms. — The onset is sudden and is characterized by the loss 
of the voice and rapidly increasing dyspnea. In severe cases a fatal 
issue may occur in from two to three hours by asphyxiation. There is 
Httle or no pain or cough. The laryngoscopic image shows the mucosa 
in the region of the aryepiglottic folds, the anterior and upper surfaces 
of the epiglottis, and sometimes the subglottic region to be tumefied. 
The surface of the mucous membrane is of a pale-gray color, in marked 
contrast to the tumefaction in phlegmonous or inflammatory edema of 
the larynx, in which it is red. 

Prognosis. — The prognosis is grave on account of the sudden develop- 
ment of the edema, and the serious nature of the constitutional disease 
back of it. If it is due to an extraneous irritation, the danger is less, 
and the liability to recurrence is less. 

Treatment. — If the disease is secondary to a serious constitutional 
disorder, this should, of course, receive appropriate treatment. For 
the immediate relief of the symptoms cracked ice should be dissolved in 
the mouth, and the patient should be assured by the attending physician 
that the dyspnea will disappear, as the sense of impending death only 
aggravates the distress. Astringent applications of cocaine and adrenaUn 
should be made. Diaphoresis and catharsis should be induced by the 
administration of Dover's powder, hot lemonade, etc., followed by the 
administration of a twelve ounce bottle of citrate of magnesia. In 
addition to the above, it may be necessary to puncture the edematous 
tissue with the laryngeal lancet (Fig. 269). If sufi^ocation is imminent, 
the patient should be tracheotomized (see Tracheotomy), to prevent a 
fatal issue. The surgeon should not hesitate to perform tracheotomy on 
a deeply cyanotic case because he does not have with him the instruments 
usually used for tliis purpose. A pocket knife, or a paring knife from 
the kitchen, may be quickly sterihzed and used to open the trachea. A 
needle and thread may be used to retract the parts until a tracheotomy 
tube is secured. In the meantime the patient's life has been saved, 
whereas to have waited for suitable instruments would have jeopardized 
his life. 

ABSCESS OF THE LARYNX. 

Etiology. — Abscess of the larynx is usually a complication of tuber- 
culous perichondritis. Perichondritis of the laryngeal cartilages is 
attended by ulceration of the mucous membrane. Infectious bacteria 
gain entrance beneath the perichondrium and cause the formation of 
pus. The accumulated pus causes a rounded tumor-like mass. This 



438 DISEASES OF THE LARYXX 

is a laryngeal abscess. It has also been known to follow erysipelas of 
the larvnx, and it may be of traumatic origin. 

Symptoms. — The abscess swelling encroaches upon the glottis, hence 
there are loss of voice and intense suffocative symptoms. It is an 
infectious inflammatory process, and causes febrile phenomena. There 
is retention and pressure, hence pain in the larynx. The laryngoscopic 
image shows a greatly swollen and reddened mucous membrane at the 
site of the abscess, tjpon puncturing it with the laryngeal lancet there 
is a free flow of pus. 




Sajous' laryngeal forceps applicator. 

Treatment. — It is obvious that there is but one method of treatment, 
namely, the evacuation of the pus with a laryngeal lancet (Fig. 269). 
This may be done under cocaine anesthesia with the patient in the 
sitting posture. The anesthesia is induced with a 10 to 20 per cent, 
solution of cocaine applied repeatedly with Sajous' forceps (Fig. 270). 
The curved laryngeal lancet should then be used with the aid of reflected 
light and the laryngoscopic mirror, or by direct laryngoscopy (Fig. 324), 
and the tumor-like mass freely incised. The relief is immediate. If 
suffocation threatens tracheotomy may be necessary. (See Tracheotomy.) 



CHRONIC LARYNGITIS. 

Definition. — Chronic inflammation of the mucous membrane of 
the larynx includes the glandular, vascular, and connective-tissue layers. 
It is usually secondary to an acute attack, or to inflammation in the 
nose, epipharynx, and tonsils, though it occasionally seems to occur as a 
primary affection. 

The following classification meets both the clinical and the })atho- 
logical recjuirements : 

1. Chronic hypertrophic laryngitis. 

(a) Diffused hypertrophic laryngitis, sometimes called chronic 

hyperemic laryngitis. 
{})) Discrete or localized hypertrophy of the mucous membrane, 

either supraglottic or subglottic. 
(c) Chorditis nodosa, or trachoma of the vocal cords. 

2. Atrophic laryngitis. 

3. Hemorrhagic laryngitis. 



CHRONIC LARYNGITIS 439 

Chronic Hypertrophic Laryngitis. — (a) Chronic Diffused Laryngitis. 
— Each of the three varieties of chronic hypertrophic laryngitis presents 
a distinct chnical and pathological picture, hence they will be described 
separately. 

Synonyvi. — Sometimes called hyperemic laryngitis. 

It is characterized by a diffused infiltration throughout the laryngeal 
mucosa, no one part being affected more than another As it is due to 
irritations of a general character, rather than to those directed against 
one part, it is easy to understand the diffusion of the hypertrophy and 
hyperemia. 

Etiology. — It is extremely doubtful if there is a 'primary chronic laryn- 
gitis, except from the improper use of the voice. It is always, or nearly 
always, secondary to a preceding disease of the nose, epipharynx, or 
the faucial tonsils. It is possible to conceive of a chronic laryngitis 
following the excessive use of tobacco or alcohol, or even following 
digestive disturbances. Clinically, however, it is rare to see cases in 
which there is not an associated or a preceding disease higher up in the 
respiratory tract. The diffused hypertrophic variety arises from ob- 
structed nasal breathing and from the discharges into the pharynx 
from the sinuses. Other sources of irritation may also be present, but 
they are generally incidental and of secondary importance. 

The etiology may be classified under the following headings: 

1. Improper preparation of the inspired air on account of nasal and 
sinus diseases. 

2. Hematogenous irritation of the larynx in mouth breathing, hepatic 
and digestive disorders. 

3. Passive hyperemia in cardiac disease, thoracic tumors and enlarged 
glands. 

4. Smoking, the inhalation of dust-laden air, the excessive use of 
alcohol, and the violent use of the voice. 

5. Climate conditions. 

6. Age and sex. 

Mouth breathing, adenoids, deflections of the septum, turbinal hyper- 
trophy, sinuitis, and polypi, also improper breathing by public speakers 
and singers, lead to a diffused irritation of the laryngeal mucous mem- 
brane. As the improperly prepared air and secretions pass over the 
whole laryngeal mucosa, there is a diffused hypertrophy. As the air 
in damp cokl weather is more irritating than it is in warm and bright 
weather, it follows that the symptoms are aggravated during the winter 
and early spring months in the higher latitudes. This is especially 
true in the region of the Great Lakes and on the northern Adantic coast 
of the United States. 

The breathing of improperly prepared air results in deficient oxygena- 
tion of the tissues and an excess of carbon dioxide in the blood. This 
in turn disturbs the metabolic processes, and still further loads the blood 
with deleterious material. This blood in circulating through the laryn- 
geal mucosa irritates all its parts, and causes a diffused hyperemia and 
liypertro[)hy. The excessive use of alcohol and tobacco similarly affects 



440 DISEASES OF THE LARYNX 

the larynx. Smoking does it by direct irritation, and indirectly through 
the blood. The ingestion of alcohol affects the larynx by direct irrita- 
tion of neighboring parts, and through the circulation, to say nothing of 
the digestive and metabolic disturbances thus aroused. The foregoing 
etiological factors predispose the larynx to acute attacks, and the chronic 
state is usually a sequel or a continuation of repeated acute inflammations. 
I am of the opinion that through disease and obstruction in the nose the 
laryngeal mucosa is kept in a state of irritability, and is made susceptible 
to chronic inflammation by the inspiration of the improperly prepared 
air and by the toxins in the blood. iVt the age of puberty boys are 
subject to attacks of chronic larsmgitis on account of the unstable condi- 
tion of the vasomoto" nervous system, the rapid development of the 
larynx, and the consequent instability of the same. Any disease of the 
heart, wherein there is an interference with the return circulation, may 
cause huskiness, and perhaps diffused hypertrophy of the mucous mem- 
brane. Thoracic tumors, or enlarged thoracic and cervical glands, also 
interfere with the return circulation, and lead to hypertrophic changes. 
Stonecutters, tobacconists, metal workers, and workers with certain 
chemicals are often affected by chronic laryngitis from the inhalation of 
the contaminated air. Men are more often affected than women, for 
obvious reasons. The aged are more prone to it on account of the 
vascular and glandular changes accompanying senility. Indeed, many 
old people living in the northern part of the United States are more or 
less afflicted with chronic laryngitis. 

Pathology. — There is a diffused hj'pertrophy of the laryngeal mucous 
membrane, including the glandular and the connective tissue. The 
bloodvessels are but little affected excepting a few small arteries on the 
surface of the epiglottis and the vocal cords, where they may be enlarged. 

Symptoms. — ^The objective s^anptoms of the diffused hypertrophic 
laryngitis, if carefully studied, are somewhat different from those of the 
other two varieties of hypertrophic laryngitis, and are as follows : 

Diffused hyperemia of the laryngeal mucous membrane, including 
that of the epiglottis, is usually present. It may be more pronounced in 
the ventricular pouches, on the epiglottis, the aryepiglottic folds, or on 
the vocal and the ventricular bands. Indeed, it often spreads from one 
part to another in the order given above, until in the later stages it is 
general. In singers and speakers the hyperemia is generally greater on, 
or is entirely limited to, the true cords. The color varies in different 
individuals, and, indeed, in the same case at different times. The cords 
may be the normal ivory white, or pinkish red, or they may be streaked 
with red, or of a pale, mottled brown or slaty gray. Enlarged blood- 
vessels are rarely seen, except upon the epiglottis and the vocal cords. 

The secretions are increased but little, indeed, in some cases they are 
apparently decreased. The image may present, therefore, either a moist 
or a dry membrane. The hyperemia is rarely demonstrable by laryngo- 
scopic examination. The mobility of the cords is usually unaffected, 
though in some cases there is a tardy action from the infiltration of the 
nuiscies. 



I 



CHRONIC LARYNGITIS 441 

The subjective symptoms have reference to the voice, the sense of 
accumulated secretions, and the ease with which the vocal apparatus 
becomes tired. The voice upon rising is often quite husky, or even 
aphonic. During the day it becomes nearly or entirely clear, unless it 
is used excessively. In this event it remains husky, and is attended by 
aching in the larynx. The secretions are rarely increased and are some- 
times diminished in quantity. 

The diffused hyperemia and hypertrophy give rise to the sense of 
accumulated secretions and the desire to clear the throat. 

Diagnosis. — ^The diagnosis is based upon the hoarseness or aphonia, the 
diffused hyperemia in the later stage, the absence of discrete hypertrophy, 
and the small amount of expectoration, except when complicated by 
bronchitis. 

Prognosis.- — ^The prognosis in the early stage is good, but when the 
hyperemia has extended over the entire mucosa it is not so favorable. 
If the laryngitis is due to the excessive use of alcohol or tobacco, or to 
an excessive or violent use of the voice, the excesses should be corrected. 
If it is due to nasal obstruction or to adenoids these conditions should 
be corrected. No matter what the cause, the prognosis as to the voice 
is bad if the hypertrophy is pronounced. In these cases there may 
be an infiltration of the thyro-arytenoidei interni muscles, thus giving 
rise to a sluggish action of the cords. 

Treatment. — From the foregoing description of the disease it is apparent 
that the treatment must be addressed to (a) the correction of the pre- 
existing nasal and sinus diseases; (6) the removal of adenoids; (c) the 
discontinuance of the use of tobacco and alcohol; (d) the correction of 
digestive and hepatic disorders, and (e) the avoidance of excessive use of 
the vocal organs. 

When the nose and accessory sinuses are the seat of a catarrhal 
or a suppurative inflammation, it should receive appropriate attention. 
Deflections of the septum, turbinal hypertrophies, sinuitis, polypi, etc., 
should be coiTected or removed by surgical procedures. Adenoids, if 
present, even though they are somewhat reduced by atrophy in adults, 
should be removed, and the associated epipharyngitis treated with silver 
applications. The faucial tonsils when enlarged or diseased should be 
removed in their entirety. The use of tobacco and alcoholic beverages 
should be forbidden, as but little benefit can be expected while the larynx 
is subjected to their deleterious effects. Singers who practice improper 
placement of the voice should either be forbidden to sing, or be taught 
})roper methods of voice building. (See the Singing Voice.) Violent use 
of the voice, either in singing or speaking, should be avoided. 

The use of sprays, gargles, and oily nebula by the patient are of little 
value. These remedies, at most, can do no more than thin the secre- 
tions and thus facilitate their expulsion. 

Local applications of a 2 to 10 per cent, solution of the nitrate of 
silver with Sajoiis' forceps should be made three times a week. The 
chloride of zinc in the same strength should be tried, although I have 
found nothing as efficacious as the nitrate of silver. Other prepara- 



442 DISEASES OF THE LARYXX 

tions of silver in my hands have proved disappointing. In making 
applications to the larynx the excess of fluid should be squeezed from 
the cotton, to prevent it trickling between the cords, where it would 
excite spasm of the laryngeal muscles. Should a spasm occur, have the 
patient take a number of deep breatlLS in rapid succession. Sustained 
efforts of this sort quickly stop the spasms. Spasms of the larynx excited 
by an excess of silver solution may be so violent as to cause cyanosis and 
extreme apprehension on the part of the patient. 

Constitutional remedies, as saline cathartics, calomel, and the iodide 
of potash, should be given if syphilis is suspected. They are often of 
value in small doses when syphilis is not present, as the cathartics 
improve the elimination, while the iodide of potash stimulates the 
glands. 

The improvement following the correction of digestive and hepatic 
disorders is often very gratifying. To this end I advise the daily use 
of one of the bitter salines in small doses, and a five-grain dose of the 
iodide of potash three times a day. In addition to these remedies it may 
be necessary to use others, according to the needs of the case. If chronic 
bronchitis is present, the administration of a ferruginous tonic, wdth five 
grains of the iodide of potash three times daily for from three to six 
months, will often effect a cure of both the laryngitis and the bronchitis. 
I recall one case that gained twenty pounds in five months under this 
treatment. 

The hygienic conditions should be good, the living and the sleeping 
rooms ventilated, and proper clothing worn. Even with all these 
precautions it is often impossible to greatly improve the quality of the 
voice. 

(6) Discrete or Localized Hypertrophic Laryngitis. — Synonyms. — 
Chronic subjective laryngitis; laryngitis liypoglottica; chorditis vocalis 
hypertrophica inferior; Stoerk's blennorrhea. 

Discrete or localized hypertrophic laryngitis is characterized by 
hoarseness or aphonia, dyspnea, a brassy cough, and an infiltration of 
the tissues in the subglottic space. 

Etiology and Pathology. — The pathological changes are the same as 
those given under the diffuse form, except they are more localized. 

Symptoms. — The subjective symptoms are about the same as those 
given under the diffuse form, but they are greatly exaggerated. The 
hoarseness usually amounts to aphonia. The hypertrophic tissue in 
the subglottic space and the infiltration of the laryngeal muscles, interfere 
with the normal movements of the cords to such an extent that approxima- 
tion is often impossible. The dyspnea, or suffocative symptoms, are 
due to obstruction in the glottis. The brassy cough is characteristic of 
obstructive swelling and hypertrophy in the subglottic region. 

The objective signs of this variety of laryngitis are quite characteristic. 
The liypertrophied tissue below the cords appears as two sausage-like 
masses, nearly parallel with and beneath the true cords. Their color, 
varies from a pale grayish pink to the pronounced red of active inflamma- 
tion. The epiglottis is also congested, enlarged bloodvessels passing 



CHRONIC LARYNGITIS 443 

over its posterior surface. In some cases there is more or less edema. 
In these cases degkitition is difficult, owing to the imperfect closure of 
the glottis. The dyspnea in discrete hypertrophic laryngitis is increased 
upon exertion. Patients sometimes complain of a sense of stuffiness, or 
of a foreign body in the larynx. After the disease is well advanced the 
above symptoms are fairly persistent, as the hypertrophic swelling is a 
fixed factor. Upon attempted phonation the cords fail to approximate, 
and instead of the free edges presenting straight lines they are slightly 
concave or wavy, owing to the weakness of the abductor and tensor 
muscles from infiltration. No doubt the hypertrophic masses in the 
subglottic region also interfere with the movements of the cords. The 
secretions are thick and whitish in color and are often accumulated in 
the interarytenoid space, and over the sluggishly moving cords. 

Diagnosis. — Rhinoscleroma presents some points of similarity, but in 
view of the fact that it is a very rare disease in this country, and that if the 
subglottic swelling is touched, under cocaine anesthesia, with a curved 
probe, it is yielding, whereas in rhinoscleroma it is hard and resistant, 
there is little difficulty in excluding rhinoscleroma. The removal of a 
piece of the growth for microscopic examination may be practised in 
case of doubt. This, when stained by Gram's method (see Rhino- 
scleroma), shows the characteristic cell formation and the bacillus of 
rhinoscleroma if that disease is present. 

Prognosis. — On account of the hypertrophic swellings below the cords, 
the dyspnea may become so pronounced as to require the performance 
of tracheotomy (see Tracheotomy), and the wearing of a tube throughout 
the remainder of life. The danger from suffocation and the pulmonary 
complications incident to the wearing of the tracheal tube render it a 
grave disease. 

Treatment. — Before undertaking the treatment the cause or causes of 
the affection should be carefully studied. When the etiology has been 
definitely determined an endeavor should be made to overcome the pre- 
disposing causes of the disease. If rheumatism, gout, dyspepsia, anemia, 
or constipation (\Yatson WiUiams) are present, appropriate remedies 
should be given. The iodide of potash and the protoiodide of mercury 
should be given in suspected syphilis, or even if syphilis is not suspected, 
as they often promote more or less absorption of the deposit. Tonic 
remedies, as iron, arsenic, quinine, gentian, and strychnine, should be 
given to promote the general tone of the system and to innervate the 
laryngeal muscles. Obstructive lesions and inflammatory diseases of the 
nasal cliambers and of the epipharynx should be remedied by appropriate 
medicinal and surgical measures. If the excessive use of tobacco and 
alcohol enter into the etiology their use should be interdicted. The 
local application of astringents, as the chloride of zinc (10 to 30 grains 
to the ounce), nitrite of silver (10 to 30 grains to the ounce), alum (5 to 
15 grains to the ounce), should be made with Sajous' laryngeal f()rce])s 
or with the spray during phonation. A change of climate or a sea 
voyage is sometimes beneficial, though not curative. I^ast, but not of 
least importance, is the absolute r(\st of the vocal organs. Tmprovcinout 



444 DISEASES OF THE LARYNX 

is sometimes striking when these preeautions are faithfully observed for 
a few clays. 

(c) Chorditis Nodosa. — Synonyms. — Trachoma of the vocal cords; 
chorditis tuberosa; singer's nodules; pachydermia laryngis. 

Chorditis nodosa, or "singer's nodules," is characterized by the forma- 
tion of nodules along the free border of one or both of the vocal cords. 
Some authors claim they are more often nearer the posterior, and others, 
that they are more often at the junction of the anterior and the middle 
thirds of the cords. The cases I have seen have been in the latter position. 

Etiology. — The nodules usually occur in connection wdth chronic 
hypertrophic laryngitis in singers and public speakers who use faulty 
methods of respiration and voice placement (Curtis). Curtis insists 
upon lower costal respiration with the upper ribs elevated, and that the 
patient should practice voice placement by attacking the initial tone 
with the lips gently closed as in humming, so that when they are plucked 
with the finger the tone flows therefrom. If the tone does not emit 
through the lips when plucked, but entirely through the nasal chambers, 
it is an evidence of faulty voice placement. When such is the case there 
is an overtension of the intrinsic and extrinsic muscles of the larynx. 
This causes attrition of the cords in phonation, hence the nodules. 
Chiari claims that chorditis nodosa is a typical pachydermia laryngis. 
Hajek thinks the nodules are glandular hypertropliies. The term as 
herein used refers to nodules from improper voice placement. 

PatJioIogy. — The nodules consist of layers of stratified squamous 
epithelium surrounded by a circle of congested tissue. They are not 
unlike corns from ill-fitting shoes. 

Symptoms. — ^As the nodes accompany a diffused hypertrophic laryn- 
gitis, the symptoms are sometimes similar to those described under that 
condition. The special subjective symptoms have reference to the 
inability of the singer or the public speaker to strike the tone he desires, 
especially in the middle register. When the cords are widely separated, 
as in the lower register, no difficulty is experienced, as the opposing 
nodes do not touch. When the higher register is attempted, the pos- 
terior thirds of the cords are necessarily closely approximated and not 
in use, and the voice is not greatly affected. When, however, the middle 
register is attempted, the cords vibrate their entire length, and as the nodes 
touch they interfere with the voice production. Hence, a prominent 
symptom is the difficulty in tone placement experienced by singers in 
attempting to use the voice in the middle register. The laryngoscopic 
image shows a nodule on the free border of one or both cords, usually 
at the junction of the posterior and the middle thirds, though the nodules 
may occasionally form anywhere along their borders. If both cords are 
involved the nodules are exactly opposite. A small area of hyperemia 
is often present at the base of the nodule. If diffused hypertrophic 
changes are present, they may not be apparent except as shown by the 
hyperemia. 

Prognosis. — The prognosis in so far as the nodules are concerned is 
good, provided the patient faithfully follows the instructions contained 



CHRONIC LARYNGITIS 



445 



in the chapter on the Singing Voice, or by practising external massage 
of the larynx, as recommended by Miller. 

Treatment. — The treatment consists in refraining from singing and 
loud speaking, and in practising proper methods of breathing and 
tone placement. This should be done under an intelligent and apprecia- 
tive instructor, which, alas! is hard to find. I have treated a few 
cases of "singer's nodules," according to Curtis' suggestions, with most 
excellent results. In none of the cases did I resort to either local, medi- 
cinal, or surgical treatment, as the nodules were apparently the result 
of faulty methods of singing. 




The endolaryngeal removal of a singer's nodule from the vocal cord of the larynx. 



If thought advisable, the astringent remedies described under discrete 
hypertropliic laryngitis may be used. In extreme cases it may be 
necessary to remove the nodules with an intralaryngeal cutting forceps 
(Fig. 271). This should be done only after failure to cure by the other 
methods suggested. Miller recommends external massage of the larynx 
with a mechanical vibrator as an adjunct to proper training in tone 
building and voice placement. The massage improves the circulation 
and nutrition of the mucous membrane, increases the local migration 
of leukocytes, and relieves the associated laryngeal inflammation. 

Atrophic Laryngitis. — Sjmonym. — Laryngitis sicca. 

Atrophic laryngitis is cliai-actcrized by a burning or pricking sensa- 
tion after exercising the voice, and by suffocative attacks (simulating 
spasmodic croup and asthma) during the night. 

Etiology. — The atrophic changes in the larynx are usually secondary 
to the same process in the nose and pharynx. Bosworth believes there 



446 DISEASES OF THE LARYXX 

is sonic influence brought to bear upon the mucous glands of tlie laryn- 
geal mucous membrane which deprives them of their secretory power, 
and that this influence is often independent of intranasal or pharyngeal 
atrophy. According to my observation, atrophic laryngitis is often sec- 
ondary tocthmoiditis and sphenoiditis, and I usually address therapeutic 
measures to these cavities as well as to the larynx. 

Pathology. — The nnicous membrane undergoes a retrograde change, 
flbrous tissue finally replacing the normal elements constituting the 
nuicous membrane and submucous tissue. The mucous glands and the 
blood vessels disappear, or become greatly diminished in size. The 
ciliated columnar epithelium is gradually replaced by squamous epithe- 
lium. The secretions are diminished in quantity and changed in quality. 
They are thicker and admixed with white corpuscles and epithelial 
debris. The desiccated secretion appears as brownish, blackish, or 
grayish crusts on the cords, and in the interarytenoid space. Ulceration 
of the mucosa is not generally present, though it may be, especially 
on the posterior wall. 

Symptoms. — After using the voice there may be a burning or pricking 
sensation in the throat. Cough, of a hoarse, spasmodic character, is 
excited by the presence of, and the attempt to remove, the crusts from 
the larynx. The cough and hoarseness are more pronounced in the 
morning. Dyspnea, simulating spasmodic croup or asthma, may occur 
at night on account of the accumulation of the crusts over the vocal 
cords. Upon laryngoscopic examination the mucous membrane appears 
pale and dry, with discolored crusts on the cords, or in the interarytenoid 
space. They may also be seen upon the posterior wall of the larynx in 
some cases, especially if there is ulceration in this region. The cords 
are dry and wrinkled and more or less covered wdth crusts. The trachea 
may be dry and glazed or covered wnth crusts. 

Prognosis. — The prognosis is bad except in those cases in which the 
atrophic changes have progressed but little. In such cases the surgical 
exenteration of the ethmoid and sphenoid sinuses may effect a cure or 
an amelioration of the diseases, provided, of course, the sinuses are 
affected. 

Treatment. — ^Tlie internal administration of the iodides occasionally 
stimulates glandular activity and thus affords relief. Pilocarpine may 
also be given for the same purpose if the heart is strong. It should never 
b(^ given without first making an examination of this organ. The 
chloride of anunonium and cubebs stimulate the glands and thins the 
secretions, rendering them easier to dislodge. The inhalation of aroma- 
tics in solution in olive oil, thrown into the larynx with a nebulizer, is 
grateful and affords temporary relief. Medicated lozenges with a 
nuicilaginous base may be used to protect the dry membrane. A warm, 
moist climate or a sea voyage will ameliorate the symptoms. Careful 
attention shoukl be given to the condition of the nose, the accessory 
sinuses, and the pharynx. If the nose is kept free from crusts and the 
secretions are increased the larynx will undergo a corresponding im- 
provement. In empyema of the posterior ethmoidal and the sphenoidal 



CHRONIC LARYNGITIS 447 

cells the secretions discharge into the pharynx and trickle downward 
into the larynx, where they become dried and adherent to the posterior 
wall, or lodge upon the cords. In such cases great improvement 
follows the radical operative treatment of the sinuses. 

Hemorrhagic Laryngitis. — Synonyms. — Spurious hemoptysis; laryn- 
geal hemorrhage; bleeding in the throat; spitting blood. 

By hemorrhagic laryngitis is meant a laryngeal inflammation accom- 
panied by hemorrhage from the laryngeal mucous membrane. The 
spitting of blood, or hemoptysis, is not always of laryngeal origin. It 
may come from the nose, the pharynx, the trachea, the bronchi, or the 
lungs. The term hemoptysis, or spitting of blood, should be limited to 
hemorrhage from the lungs, and especially that occurring in tuber- 
culosis. 

Etiology. — Hemorrhage occurring in the course of laryngitis is due 
to ulcerations, acute inflammations, and the excessive use of the voice. 
Syphilis and tuberculosis of the larynx may be attended by laryngeal 
hemorrhage. Albuminuria, diabetes, variola, typhoid fever, yellow 
fever, leukemia, hemophiha, and malignant disease also predispose to 
hemorrhages. 

Symptoms. — If a chronic laryngitis is present the usual symptoms of 
such a condition are present. (See Chronic Laryngitis.) Added to this 
the patient complains of a tickling sensation in the throat, followed by 
cough and the expectoration of blood. The quantity varies from a mere 
streak to a mouthful; usually, however, it is small. 

The laryngoscopic examination shows one or more areas of extra- 
vasated blood on the cords or mucous membrane, and perhaps some 
fresh fluid blood may still cling to the surface of the laryngeal mucosa. 

Treatment. — Ordinarily no treatment is required. Astrigent sprays 
and the external application of ice may be tried. If the coughing is 
continued, it should be quieted by the administration of morphine by 
hypodermic injection (Coakley). The act of coughing prevents coagula- 
tion and tends to prolong the bleeding. 

General Diagnosis of Chronic Laryngitis.— The differential diag- 
nosis of chronic laryngitis from other laryngeal diseases is not always 
easily made. It may be confounded with laryngeal tuberculosis, syphiUs, 
adenitis, carcinoma, and certain benign growths. 

Tuberculosis is characterized by a rapid pulse, elevation of tempera- 
ture, loss of appetite, emaciation, and a general lowered vitaKty. These 
symptoms are not present in chronic laryngitis. An examination of 
sputum for tubercle bacilli will still further aid in the diagnosis. A 
laryngoscopic examination does not always settle the diagnosis, luiless 
the larynx is the seat of the tuberculous infiltration. In most cases of 
tuberculosis the laryngeal mucosa is ashen gray in contrast with the 
difl'uscd hyperemia of chronic laryngitis. In the inflammatory type of 
laryngeal tuberculosis (mixed infection) the mucosa is red, but the 
swelling of the arytenoid cartilages is too great to be mistaken for catarrhal 
inflammation. 

If the tuberculous process is well advanced ulcerations may be present. 



448 DISEASES OF THE LARYXX 

Syphilitic affections of the larviix may present niiicli the same appear- 
ance as the edematous type of chronic laryngitis. Hyperplasia may be 
present in both diseases, but is more often present in sypliiUs. Careful 
inspection will often reveal small ulcers, which condition lends to the 
diagnosis of syphilis. An accurate history of the case is, therefore, 
necessary to make the differential diagnosis. In the tertiary stage the 
diagnosis is easily made. The ulcers in h}^ertropliic larjiigitis are 
stationary, while those of syphilis and tuberculosis are deep and spread 
rapidly. 

Carcinoma in the subglottic region is distinguished from discrete 
hypertrophic laryngitis by the nodular outhne of the growth and the 
cachexia present. Perichondritis in this region more nearly simulates 
carcinoma on account of the nodular outline of the tumor-like mass. 

In lupus the surface of the membrane is markedly red and granular. 

Sarcoma of the larynx presents a red and an uneven contour, whereas 
in all forms of hypertrophy the swelling and purulent discharge come 
on before the perichondritis becomes manifested. 

Enchondrosis of the laryngeal cartilages is differentiated from edema- 
tous laryngitis by the sense of hardness on probe pressure and the un- 
even contour of the swelling. 

Paralysis of the posterior crico-arytenoid muscle may be mistaken 
for subglottic hypertrophy unless a careful examination is made. In 
paralysis the lagging movements of the cords reveal the nature of the 
lesion. The paralysis may also be mistaken for pachydermia laryngis. 

Prolapse of the ventricles is differentiated from superior hypertrophy 
by the pronounced pitting upon probe pressure. 

Angina laryngis is differentiated from hemorrhagic laryngitis by the 
elevated whorl of blootl vessels and the absence of hemorrhage. 

Papilloma is distinguished from chorditis nodosa by the point of 
attachment, and the size and shape of the growth. 



f DIPHTHERIA; TRACHEOTOMY; INTUBATION. 

Definition. — Diphtheria is an acute infectious disease, characterized 
by the presence of the Klebs-Loeffler bacillus. It is still further char- 
acterized by a false membrane on a mucous surface or an abraded skin, 
and is communicable, either directly or indirectly, from one person to 
another. The lesion is usually located in the upper respiratory tract. 

Etiology. — As to its geographical and racial distribution, it may be 
said to be well-nigh universal. No cUmate, season, country, or race is 
exempt from its ravages. It is, however, less prevalent in the summer 
season in temperate and northern latitudes, on accoimt of the open-door 
life of the people at this season, and an account of the school vacations, the 
overcrowding, and the close contact incident to school life being tempor- 
arily suspended. Statistics show that among the poor in crowded 
tenements, and in illy ventilated school-rooms, the cHseaseis more preva- 
lent. A curious exception to this is shown by Walsh to exist among the 



DIPHTHERIA 449 

negroes of Washington. The percentage of diphtheria among 10,000 
negroes was 4.43, as against 15.25 per cent, among the same number of 
whites. Tliis may be due to an antitoxic state of the blood in the negro 
race, or to a greater freedom from disease of the upper respiratory tract. 
(Nasal obstruction is comparatively rare among negroes.) 

Sanitation is an important factor in the development of the disease. 
Sunshine and fresh air are twin sisters of charity in the prevention and 
the amelioration of infectious diseases. In one of the great children's 
hospitals of I^ondon, diphtheria was prevalent in one of the wards. As 
soon as they were convalescent the patients were removed to another 
ward and no recurrences were reported. An adjacent building was torn 
down and the solid iron shutters of the convalescent ward were closed 
to exclude the dust. Incidentally the sunshine and the fresh air were 
also excluded, and there were many recurrences among the convalescents. 

The overcrowded tenement districts in the great cities are usually 
poorly ventilated and the rooms little exposed to the sunshine. When 
many are in close contact, the opportunities for transmitting the infection 
are multiplied, hence, for these and other reasons the poor of the cities, 
are especially afflicted with diphtheria. 

Defective plumbing, sewer gas, cesspools, etc., are often charged with 
the production of the disease. While these may indirectly influence 
the spread of the contagion, it should be remembered that the Klebs- 
Loeffler baciflus is absolutely essential to the production of the true 
disease. The presence of sewer gas may produce lessened resistance to 
the diphtheria bacilli, and thus predispose the patient to their ravages. 

Bodily conditions have much to do with the susceptibility of the 
individual exposed to the Klebs-Loeffler bacillus. The "scrofulous 
habit" lowers the tone of the cellular elements of the body and thus 
renders it less fit to cope with the inroads of the disease-producing germ. 
Abraded or diseased surfaces in the upper respiratory tract also offer 
local lowered resistance areas for the growth of the bacilli. Hence 
enlarged and diseased tonsils, adenoids, glandular enlargements of the 
neck, and catarrhal diseases of the nose and throat favor the development 
of the diphtheritic process. 

Rich and poor alike are affected, the only difference being the more 
favorable sanitary conditions surrounding the rich, who are, therefore, 
relatively less often affected. 

Age has a decided influence on the prevalence of the disease. The 
blood of nurslings is decidedly antitoxic in its properties, hence children 
under one year of age are comparatively exempt from the disease. 
After the fourteenth year there is relatively slight liability to diph- 
theria. Baginsky shows by the statistics of 2711 diphtheritic cases that 
under six months the percentage of cases is 0.55; six months to one year, 
2.5 per cent.; one to two years, 8.3 per cent.; two to three years, 11.6 
per cent. ; three to four years, 13.05 per cent. ; four to five years, 12.4 
per cent.; five to six years, 9.7 per cent.; six to seven years, 10.3 per 
cent.; seven to eight years, 7.7 per cent.; eight to nine years, 6.4 per 
cent.; nine to ten years, 5.5 per cent.; ten to eleven years, 3.7 per cent.; 
29 



450 



DISEASES OF THE LARYNX 



eleven to twelve years, 2.9 per cent.; twelve to thirteen years, 2.02 per 
cent.; thirteen to fourteen years, 2.0 per cent. (Fif^. 272). 

Modes of Infection, Direct and Indirect. — The direct infection is from 
the one affected to another, i.e., by breathing the atmosphere immediately 
surrounding the patient, inhaling his breath, or receiving the mucous or 
the saliva into the mouth or the nose during an act of coughing, spitting or 
sneezing on the part of the patient. Kissing is another mode of direct 
infection, and is to be condemned when diphtheria is known to exist in 
the family. All members of the family should refrain from this manifesta- 
tion of affection during the term of diphtheritic infection in its ranks, 
as there may be a mild or an incipient infection without the knowledge 
of the individual. AVithout doubt many cases are often transmitted by 
persons who are not suspected of being infected. 

The indirect mode of infection is not so easily traced as the direct; 
nevertheless, it is well established that the bacilli may be transmitted 
by domestic animals, as dogs, cats, chickens, rabbits, etc., which, being 



PERCENTAGE 


1 a 


3 4 6 


6 


YEAR 
7 8 





lU 11 12 


i;i 


14 


US 

13 J 
127, 

m 

10 7, 

9 5; 

87< 
75? 
Of. 
H 

37< 
2S 
H 
















1 








































/ 


^v, 
























J 






\, 






















/ 






s 


^ 


^ 


















/ 










s 


















' 










\, 
















/ 












s 
















/ 




























/ 
















\ 


k 










/ 




























/ 




















k 






y 


( 




















^ 


— 




/ 




























/ 





























above chart is arranged from the statistical data of Baginsky, and shows at 
relative prevalence of diphtheria from birth to fourteen years of age. 



glance the 



directly exposed to the contagion, convey it to persons removed from the 
direct source of infection. The author recalls a case which aptly illus- 
trates this point. He was in the house of a minister when a member 
of the parish called to make the funeral arrangements for his child, who 
had just died of diphtheria. 

The man was accompanied by a collie, which w^as hugged and fondled 
by the four-year-old son of the minister. Within a few days the boy was 
ill with diphtheria, having no doubt received the infection from the collie. 
It may also be conveyed by towels, table-linen and dishes, bedding, books, 
wall-paper, carpets, rugs, clothing, and all other articles bathed in the 
germ-laden atmosphere surrounding a diphtheritic patient. Food may 
be the source of infection, milk being especially accused in this connection. 

The hands and the clothing of ])hysicians, nurses, and parents should 
be mentioned as sources of infection. 

The custom of serving the elements at communion services in churches 
from common cups is to be condemned as a possible mode of conveying 



DIPHTHERIA 451 

contagious diseases. Individual cups should be used, thereby minimizing 
if not absolutely removing the danger. The church should be as cleanly 
in its table manners as its individual members are in their homes. There 
they do not tliink of drinking from a common vessel, each member and 
each guest being provided with -one for his individual use. The same 
decent, cleanly, sanitary custom should prevail in ecclesiastical functions. 

The disease may be endemic, epidemic, or sporadic in its manifestations 
in a community. The mode of manifestation is largely due to the 
density and the numerical strength of the settlement. In large cities, 
where there are large numbers congregated in small areas, diphtheria 
is epidemic, coming as a tidal wave of infection and carrying many away 
in its course. The community may then be free from the disease for 
months or years. The sporadic or isolated cases are more difficult to 
explain, but we know that the Klebs-Lneffler bacillus must be present. It 
is known that it may hve under varying and pecuHar conditions for a 
long time, and the sporadic cases are often to be explained by the latent 
existence of the germ, which suddenly becomes virulent and gives rise 
to the isolated attacks of the disease. 

Bacteriology. — ^The Klebs-Loeffler bacillus being the specific cause of 
diphtheria, its characteristics and the methods for its detection are im- 
portant. The announcement of Klebs in 1883 that he had discovered a 
bacillus which was constantly present in the false membrane of diph- 
theritic patients, marked an epoch in the history of medicine, and soon 
revolutionized the methods of treating diphtheria. Loeffler in 1884 made 
pure cultures of the bacillus, and inoculated the mucous membranes of 
animals, getting the characteristic pseudomembrane of diphtheria. In 
1888-89, Roux and Yersin reported the results of their experiments rela- 
tive to the toxins produced by this germ. Serumtherapy thus had its 
beginning. 

The Klebs-Loeffier bacilU vary greatly in size, shape, and curvature, 
according to the medium in which they are grown, and often vary in the 
same medium. They also vary with the fluidity, the age, and the tempera- 
ture of the medium, but they generally present the appearance of narrow 
rods, straight or curved, swollen at either extremity, and are found in 
groups with a tendency to parallelism. They are not always parallel, 
but may have a tangled, irregular arrangement, or be in broken chains. . 

The atypical forms may be thickened at one end only, or at the centre 
of the rod, the extremities being pointed. They may also be lance-, 
spindle-, or club-shaped, or even pear-shaped. One characteristic is 
always present, namely, segmentation. 

The Klebs-Loeffler bacilli stain readily with alkaline methylene-blue 
and many other aniline dyes. 

Northrup gives the following directions for the preparation of Neisser's 
stain and its application to the differentiation of the diphtheritic germ: 

"No. 1. — 1 gm. methylene-blue dissolved, 20 c.c. of 96 per cent, alco- 
hol, 90 c.c. distifled water, .50 c.c. glacial acetic acid." 

"No. 2. — 2 gm. vesuvin to 1 liter of lK)iling distilled water. 

"The culture is stained in No. 1 for one to three seconds, or, better, 



452 DISEASES OF THE LARYNX 

somewhat longer; washed off in water and stained with No. 2 for three 
to five seconds or longer; washed off and mounted. Colored in this 
way, a twenty-four-hour-old culture on blood serum or bouillon will 
show the body of the bacilli stained brownish yellow, while at one or both 
ends may be frequently seen the so-called polar granules (Neisser-Ernst 
bodies) as deeply colored blue, oval-shaped areas, the diameter of which 
is greater than that of the bacillus in which they are found. The out- 
lines of tlicse bodies are sharply defined, and they are not pecuHar to 
true diphtheria bacilli, but are found occasionally in a shghtly atypical 
form in certain forms of pseudodiphtheria bacilli, especially in older 
cultures." 

The diphtheria bacilli may be grown upon blood serum, agar-agar, 
bouillon milk, etc., and they are pathogenic for pigeons, rabbits, guinea- 
pigs, chickens, certain small birds, cattle, goats, and horses. 

Bacteriological Diagnosis. — A portion of the pseudomembrane should 
be removed from the throat of the patient with an aseptic cotton-wound 
probe, wire loop, or other instriunent, and smeared over a clean cover- 
glass, dried and stained with Roux's double stain of dahlia violet and 
methyl green, or with Loeffler's blue-staining solution. 

The coverglass thus prepared should be mounted and examined with a 
microscope. The diphtheritic bacilli, if present, will be readily recognized 
by their typical appearance. If not found, a culture in blood serum 
should be made, which, in from twelve to twenty-foiu' hours, in a tempera- 
ture of 37° C, will develop grayish colonies, the size of a pinhead, with 
regular outline, the surface being dry. Held to the light, the periphery 
is translucent, the centre being somewhat opaque, on account of its greater 
thickness. 

Upon the above appearances and reactions a fairly positive diagnosis 
of diphtheria may be made. 

The streptococcus is developed much slower (twenty-four to seventy-six 
hours), the colonies are white, and pinpoint in size. 

The staphylococcus develops slower than the diphtheritic bacillus, 
but faster than the streptococcus. It presents the appearance of a 
flocculent or white colony much larger than a pinhead, and has a halo- 
like border. The areas are darker in the centre. 

A negative result with the microscopic examination, or with the cul- 
tures, does not justify a positive statement that the case is not one of true 
diphtheria. The author knows of an instance in which seven different 
examinations were made by an expert bacteriologist and pathologist, 
before the Klebs-Loeffler bacillus was found. 

]\Iixed infection is the rule, hence a case of siinple diphtheria is not 
commonly seen in practice. The Klebs-Loeffler bacilli are usually 
associated with streptococci, staphylococci, and diplococci, and the symp- 
toms and the progress of the disease are modified accordingly. Again, 
virulent diphtheria bacilli may be present in a healthy throat without 
giving rise to any symptoms. Should, however, these same bacilli be 
hxlged in a throat with enlarged, ragged tonsils there is every prob- 
ability that the ])erson would be affected by true diphtheria. Mixed 



DIPHTHERIA 453 

infections are more serious than simple, as the accessory germs may 
produce severe pathological changes, independent of the diphtheritic 
process. 

The Systemic Distribution of the Bacilli.— Many investigators report 
the presence of Klebs-Loeffler bacilli in pneumonic areas and lymphatic 
glands, but they are generally associated with other germs. They have 
been found in the lungs, the spleen, the bone-marrow, the liver, the 
nasal accessory sinuses, the heart's blood, and they are probably in 
other tissues of the body. 

Pseudodiphtheria Bacilli. — There are two schools of thought regarding 
the so-called pseudobacilli of diphtheria: (a) The larger school holds 
that the pseudodiphtheria bacillus is under no circumstances convertible 
into the true diphtheria bacillus. (6) The smaller school holds that 
the two germs are identical. The scope of this work will not permit of 
a presentation of the data upon which these two schools of thought rest 
their claims. Suffice it to say that the two germs are differentiated, 
according to the first or larger school, by their mode of development on 
various culture media, their morphology, and their pathogenicity. 

Histopathology. — The distribution of the false membrane may involve 
the mucous membrane of the nose, the pharynx, tonsils, hard and soft 
palate, mouth and lips, larynx, trachea, the bronchi from the largest 
to the smallest, the ear, and abraded surfaces of the skin. The vagina, 
the duodenum, the conjunctivae, and other mucous membranes may 
also be involved. 

In about 75 per cent, of the cases the membrane is above the larynx. 
In 15 per cent, of the cases the larynx is involved. Previous to the use 
of antitoxin, autopsies often showed the pseudomembrane extending 
from the tip of the nose to the smallest bronchi; since the use of antitoxin 
it is rarely found so extensively distributed. 

The appearance of the pseudomembrane varies from a pale yellow 
through a dirty brown to a black color. Its consistency is usually 
tough and leathery, although it may be friable. It is firmly attached 
to the underlying tissues when found on the uvula or the pharyngeal 
wall, and loosely attached in the trachea. 

The formation of the pseudomembrane begins with an exudation of 
lymphatic cells, which rapidly undergo coagulative necrosis, leaving a 
reticulated substance composed of fibrin from the broken-down cells. 

If the fibrin penetrates the deeper layers of the mucosa, it is difficult 
to remove it, as the line of demarcation is not easily established between 
the living and the dead tissue. If, on the other hand, the fibrin remains 
superficially attached, it is easily removed, for obvious reasons. When 
the pseudomembrane is deeply attached, its removal is attended by some 
bleeding; if superficially attached, there is no bleeding. 

Sloughing of the mucous membrane may occur when the bloodvessels 
supplying it become degenerated, thrombosed, or otherwise injured, so 
that the nutrition supplied to the parts is shut ofl". This is often spoken 
of as "gangrenous diphtheria." 

It is seen by the foregoing statement of the varying appearances and 



454 DISEASES OF THE LARYNX 

conditions of the pseudonienibrane of diphtheria that the picture pre- 
sented is kaleidosco})ic in character. Its appearance in the early stage 
is usually as a whitish or yellowish, circumscribed film, and, at a still 
later period, it may become yellowish or dirty brown in color. If hemor- 
rhage takes place beneath or within the false membrane it may become 
black. 

According to Northrup, the pathological changes in various parts of 
the body have been shown by numerous writers, and only a brief men- 
tion of them can be made here. 

The nervous system is involved in some cases, with degeneration of 
the posterior roots (Bikeles and KaUsko) where they enter the gray 
matter of the posterior cornua, thus accounting for the ataxic symptoms 
occurring in diphtheritic paralysis. Manicatide reports his findings as 
follows: 

(a) Purely muscular changes with no nerve involvment. 

(6) Polyneuritis. 

(c) Lesions of the spinal cord, which were either localized in the gray 
matter, leading to atrophy of muscles, or involving the white matter of 
the cord, in a similar w^ay to that seen in locomotor ataxia or multiple 
sclerosis. 

(d) Cerebral paralysis, chiefly due to circulatory changes. 

The heart undergoes degeneration, chiefly fatty. This simple type 
of degeneration precedes the more destructive hyaline changes, which 
lead to the loss of the sarcous elements. The changes are due to toxins. 

The lungs are, in about 60 per cent, of cases, affected by broncho- 
pneumonia. True lobar pneumonia has not been found. 

The spleen is affected by cell infiltration in the splenic •follicles. In the 
centres of the follicles masses of epithelial cells are sometimes found. 
There is local edema of the centre or the periphery of the follicles. 
Necrotic areas and hyaline changes are also present. No bacteria have 
been found in sections of the spleen. 

The lymphatic glands first undergo congestion and hemorrhage and 
there is dilatation of the lymphatic sinuses. Later, foci very similar 
to miliary tubercles form, by a process of proliferation, phagocytosis, 
and degeneration. These changes are due to the toxins formed Jby the 
lymphatics and not to bacteria. The same changes, with minor modi- 
fications, take place in the tonsils. 

The thymus gland undergoes the same changes described under 
lymphatic glands. 

The skeletal muscles undergo fatty degeneration. 

The bone-marrow undergoes hyperplastic changes. 

The pancreas has not been found involved in autopsies following true 
dij)htheria. Hibbard and Alorrissy found glycosuria in 25 per cent of 
230 patients. Others have failed to find it so commonly present. 
Examinations for sugar should he made in every case of diphtheria. 

The alimentary canal may be affected by true diphtheria of the 
stomach. The pseudomembrane has not been found in the intestine. 

The liver undergoes degenerative changes, ranging from simple fatty 



DIPHTHERIA 455 

to hyaline degeneration. Focal necrosis is the most characteristic 
change in this organ in diphtheria. 

The kidneys undergo fatty and hyaline degeneration. Casts are pres- 
ent. There are also interstitial changes in about 25 per cent, of cases 
examined. There is an increase in the cells of the glomeruh, and some- 
times necrosis with hemorrhage into the capsular space is present. 

Types of Diphtheria. — Before considering the symptomatology, it 
will be well to briefly consider the various types of diphtheritic mani- 
festations. It is often described according to the seat of local manifesta- 
tion as angina, local or general; nasal diphtheria; bronchial diphtheria; 
broncholaryngeal (ascending) diphtheria; conjunctival diphtheria; aural 
diphtheria; vaginal and rectal diphtheria, etc. 

Monti's classification, according to Northrup, in Nothnagel's Encyclo- 
pedia of Practical Medicine, is as follows : 

Catarrhal Diphtheria (Bacteriological Diphtheria; Diphtheria Fruste).— 
This type is characterized by simple redness and swelling of the tonsils 
and the pharynx, with no false membrane. Microscopic examination 
shows the Klebs-Loeffler bacilli present. Spontaneous recovery occurs 
in a few days. The germs, transplanted into another throat, might give 
rise to a more severe type. Careful quarantine should be maintained 
to prevent the spread of the disease. 

Fibrinous Diphtheria. — This type is due to the action of the Klebs- 
hoef^ev bacilli uncompHcated by any other germ. It may be purely 
local in its character, the membrane and the slight redness surrounding 
it being the only symptoms; or it may be general, with a tendency for 
the false membrane to spread to other parts, with great toxemia and severe 
complications. It is more often local in its manifestations. Microscopic 
findings: the Klebs-LoefHer bacilli. 

Mixed, Phlegmonous, or Streptodiphtheria. — This type is characterized 
by great inflammatory reaction in the neighborhood of the pseudomem- 
brane, and by the presence of the Klebs-Loeffler bacilli with some other 
pathogenic organism, usually the streptococcus, and their toxins. Mixed 
infections are more dangerous, and experiments on animals (Roux and 
Martin) show that antitoxin has little or no effect in checking the ravages 
of this type of infection. 

Septic or Gangrenous Diphtheria (Septicemia). — In dealing with this 
type, we are essentially treating septicemia of diphtheritic or of mixed 
infectious origin. It is usually of mixed infection (Klebs-Loeffler, 
streptococci, and staphylococci) origin, although in rarer cases it seems 
to originate from the simple Klebs-Loeffler bacillus infection, which has 
assumed the so-called gangrenous diphtheria type. In other words, 
what started out as a simple diphtheria later became complicated by 
other germs and their toxins, a true septicemia resulting. It is doubtful 
if true septicemia ever results from pure Klebs-Loeffler bacillus infection. 

General Symptomatology. — The disease is ushered in by a feeling of 
discomfort, lassitude, loss of appetite, constipation, slight sore throat, 
didiculty in swallowing, and more or less hoarseness. 

The teni'perainre varies with the type, but has certain characteristics 



456 DISEASES OF THE LARYNX 

which may he recognized. For instance, even in the fibrinous type, 
which is the least febrile, there is a rise of temperature with the beginning 
of the formation of the meml)rane. It is commonly said that this type is 
not attended by fever. Notwithstanding, it will be found, and there will 
be a recurrence of elevated temperature with each extension of the pseudo- 
membrane to a new part. In all types of diphtheria there is an increase 
of temperature with each extension of the local field of infection. There 
is a greater fluctuation of the temperature curve in the mixed infection 
and the septic type than there is in the catarrhal and the fibrinous 
varieties. 

The pulse rate is invariably increased in uncomplicated cases, in the 
beginning, in proportion to the toxic products eliminated. The pulse 
rate in infants is especially liigh. 

Brachycardia (slowing of the pulse rate), if persistent, is a grave 
symptom. 

Tachycardia (increased pulse rate), when reaching a rate of 140 or 
more, is a grave symptom. At 140 the death rate is about 20 per cent., 
increasing to 90 per cent, at a pulse rate of 180. Nasal diphtheria is 
usually the cause of the tachycardia, hence the occurrence of a rapid 
pulse should at once lead to a critical examination of the nasal fossfe. 
The nose is very richly supplied with lymphatic tissue, hence the rapid 
absorption and the toxic symptoms. 

Reduced blood pressure, as shown by sphygmographic tracings, indicates 
an increased absorption of diphtheria toxins, and warrants a grave 
prognosis. The same is true of an intermittent pulse. 

Partial angina is the most common anatomical form of the disease. 
Early there is a general redness of the pharynx and the pillars of the 
fauces. At the site of pseudomembrane formation, which is usually 
the tonsil, there is increased redness. It may form, however, on the 
posterior pillars, the uvula, or the walls of the pharynx. First one tonsil 
is involved, then the other. The cervical glands are somewhat swollen 
and tender. Temperature elevated 1° to 2° with frequent oscillations. 
General health good. Transient albuminuria. Course, six to eight days. 

General or toxic angina is characterized by a thicker and more exten- 
sive pseudomembrane, gray or dirty yellow in color, or even brown or 
black. The whole, or nearly the whole, of the tonsils, the pillars (arches), 
the uvula, and the pharyn;s: are covered by the membrane in from three 
to six days. Grave symptoms appear early, usually ushered in by a 
chill followed by fever. Delirium, restlessness, apathy, and vomiting 
are often present. Swallowing becomes difficult on account of the 
swollen and stiffened condition of the fauces and the pharynx. The 
epipharynx (nasopharynx) is filled with tenacious mucus. The 
cervical glands are swollen and tender. Albuminuria is pronounced. 
Without treatment the pseudomembrane may be cast off and be reformed, 
continuing thus for three to six weeks. Under proper treatment the 
disease may be brought imder control in from three to six days. 

Phlegmonous or streptodiphtheritic angina involves the entire throat 
from the beginning. The mucous membrane is dark red, and the uvula 



DIPHTHERIA 457 

swollen. Witliin a few hours a dirty gray or blackish membrane forms, 
and rapidly spreads. The cervical glands are much swollen and very 
tender. While the membrane is forining and spreading, the temperature 
is elevated. Toxic symptoms, as rapid pulse, delirium, restlessness, 
apathy, etc., set in after the membrane has reached its limit. The 
temperature usually drops at this time. Albuminuria often appears 
witliin forty-eight hours. Under antitoxin treatment the disease may 
be controlled in from five to six days. In obstinate cases the kidneys 
and the heart may become involved and thus complicate the case. 

Septic angina is characteristic of certain epidemics, although it usually 
develops from the phlegmonous variety. The symptoms are most 
grave from the beginning. Vomiting is violent and attended by extreme 
prostration. The temperature curve rises very suddenly. The pulse 
is small, soft, and rapid. Respiration is increased proportionately. 
The tonsils and the fauces are swollen. They are a livid bluish white, 
with discolored spots. Bloody matter is mixed with the exudate. The 
cervical glands are very much swollen and tender on both sides. Death 
occurs usually on the second to the fourth day, from collapse and general 
sepsis. 

Diphtheria of the nose may assume any one of the foregoing types, 
although it is probably more often of the simple fibrinous type. It 
may be primary or secondary. The upper lip is excoriated by the nasal 
discharge. The child "snuffles," sleeps a great deal, and takes food 
poorly on account of the nasal occlusion, and he may become cyanotic 
in attempting to nurse the breast. The glands of the neck are swollen. 
Nasal hemorrhage occasionally takes place. Many cases run a benign 
course, while others are malignant from the beginning, death occurring 
within a few days. In older children the disease runs a more favorable 
course. In scrofulous children it may be more chronic, often extending 
over many weeks. 

The nasal occlusion is at first often thought by the parent to be due to 
a foreign body in the nose. The membrane is usually situated on the 
septum, although it frequently involves the whole Schneiderian membrane, 
and may be removed with the forceps or the syringe, as a cast of the 
interior of the nose. 

In phlegmonous, mixed, or streptodiphtheria of the nose the symptoms 
are more pronounced from the beginning, the membrane is mixed with 
blood and appears black (black diphtheria). Toxic symptoms are 
marked, and the glands of the neck much swollen and tender. The 
patients are little inclined to take food. Early and vigorous treatment 
is often followed by recovery. The disease is, however, to be regarded 
as very grave in its nature. On accoimt of the rich lymphatic supply 
of the nose, the sej^tic form of nasal diphtheria is especially serious. 

Laryngeal Diphtheria (True Croup; Membranous Croup; Diph- 
theritic Croup, Etc.). — Laryngeal diphtheria may be primary, although it is 
usually secondary to diphtheria of the nose, the pharynx and tonsils, 
the trachea and the bronchi. On account of the great danger, and at 
the same time a possibility of a favorable issue under proper treatment, 



458 DISEASES OF THE LARYNX 

we will, according to Northrup, enter into a brief but careful analysis of 
this type of (liphtheria. It should be studied under three headings, 
namely: (1) Stage f)f invasion; (2) stage of spasm — exudation; (3) 
stage of asphyxia. 

Stage of Invasion. — This is characterized by a simple angina becoming 
suddenly complicated with hoarseness, and a cough characteristic of 
laryngeal irritation. The Klebs-Loeffler bacillus may or may not be 
found. A negative finding is not conclusive, however, as heretofore stated. 

Stage of Spasm (Exudation). — The pseudomenibrane may develop so 
rapidly that within twenty-four hours there is laryngeal stenosis. The 
cough is dry, short, and hoarse, becoming paroxysmal in character and 
often lasting for several minutes. It is attended by cyanosis, full veins, 
and a perspiring forehead. Aphonia, more or less complete, soon 
develops. The respiration is wheezing and noisy. As the stenosis 
becomes more advanced, the inspiratory act is prolonged and is attended 
by a whistling noise. There is pronounced depression of the supra- 
clavicidar region, the neck, and the epigastrium. The severe symptoms 
come in waves; extreme cyanosis, and harsh, difficult respiration, giving 
way, temporarily, thus affording the little sufferer a brief respite from 
the aggravated symptoms. The natural duration of this stage is from 
one-half to seven days. 

Stage of Asphyxia. — This stage is characterized by greatly impeded 
respiration and toxic symptoms. The respiration becomes more rapid 
and irregular, the child sits up suddenly, and falls back again exhausted. 
The cyanosis and the retraction of the supraclavicular, the jugular, and 
the epigastric regions is more pronounced. The suffocative attacks occur 
more frequently. The head is thrown back, and all the accessory 
muscles of respiration are called into action. Even the abdominal 
muscles are retracted. The larynx rises with each inspiratory effort. 
During one of the suffocative attacks, complicated with convulsions, 
tleath comes. According to Monti, in untreated cases the death rate is 
from 95 per cent, to 98 per cent. Under modern methods of treatment 
tlie death rate is small in cases taken early. 

Phlegmonous or Mixed Infection of the Larynx. — It is usually secondary 
to a similar process in the nt)se or the throat, and is characterized by 
great redness of the mucosa of the larynx and the trachea, with some 
grayish pseudomembrane scattered here and there in the larynx and the 
trachea. The stenosis of the larynx is not so marked as in the preceding 
type, nevertheless, death may occur suddenly from it. The toxic symp- 
toms are also pronounced in this type, and no doubt contribute toward 
a fatal result. 

Septic Diphtheria of the Larynx. — This is also secondary to a similar 
process in the nose or the throat, or both, and begins with fever, apathy, 
and marked weakness. The mucous membrane of the larynx and the 
nose is swollen, and covered with a grayish-yellow exudate. Toxic 
symptoms, as vomiting, delirium, suppression of urine, heavily coated 
tongue, rapid pulse, etc., are pronounced. The prognosis is quite 
grave. 



DIPHTHERIA 459 

Causes of Asphyxia in Diphtheria. — Four theories have been advanced : 
(a) Spasm of the glottis; (6) obstruction by pseudomembrane; (c) 
paralysis of the dilators of the glottis; (d) excitation of the respiratory 
centres by carbonic acid poisoning, and reflex action of the pneumo- 
gastric nerve. 

Autopsies have shown many instances of death from asphyxia when 
there was little or no false membrane to account for it. This leaves spasm 
of the glottis, paralysis of the dilators, and the irritation from carbonic 
acid as possible theoretical explanations. The latter two have but few 
supporters; hence the probable explanation of the majority of cases is to 
be found in the first theory, namely, spasm of the muscles of the larynx. 

Diphtheria of the Trachea and the Bronchi. — This is usually second- 
ary to laryngeal diphtheria, although it may occur primarily in the bronchi 
or the trachea. Where it thus forms, and the larynx is secondarily 
involved, it is known as "ascending croup." If a cast of the bronchi is 
coughed up, it is a positive sign of bronchial involvement. Other signs, 
as respirations 50 to 60 per minute, continuous dyspnea (as contrasted with 
intermittent when the pseudomembrane is in larynx and upper trachea), 
supraclavicular and epigastric depressions not so well marked, pale face, 
blue lips, and great physical depression, may aid in reaching a diagnosis 
of bronchial diphtheria. The prognosis is very grave. 

Diphtheria of the Ear. — ^This is usually carried to the external ear 
by scratching (abrasion) with the infected fingers of the patient. Infec- 
tion of the external auditory meatus is seen in rare instances in which 
there is diphtheritic otitis media with extension through the tympanic 
membrane. 

Otitis media complicating diphtheria occurs in only about 4 to 6 per 
cent, of the cases. When present it is characterized by deafness, pain 
in the ear upon swallowing and coughing, followed by aural discharge, 
after which the pain subsides. 

Diagnosis. — The differential diagnosis of diphtheria should be made 
between (a) peritonsillar abscess; (6) follicular tonsillitis; (c) pseudo- 
diphtheria; {d) pseudocroup; and (c) catarrhal rhinitis, the chief diag- 
nostic point in each case being the microscopic and the culture findings. 

Prognosis. — This may be summarized under the following headings: 

(a) The Age of the Patient. — The mortality is the lowest in the first 
year and the tenth year, and the highest in the second to the sixth year 
of life. 

(6) The Site of the Local Lesion. — ^The larynx furnishes the highest 
mortality. Nasal diphtheria in infants is very fatal. 

Treatment. — ^Antitoxin treatment has reduced the cases coming to 
operation one-half. The death rate in laryngeal cases under antitoxin 
has been reduced from 70 per cent, to 16 per cent. Intubation is 
attended by a better mortality table than tracheotomy. 

Time of Beginning Treatment. — Briggs and Guerard have compiled 
the following table: 



460 DISEASES OF THE LARYXX 

Mortality 

Cases. Deaths. Per cent. 

First day of disease 1415 5 3.5 

Second day of disease 2640 213 8.0 

Third day of disease 2340 300 12.8 

Fourth day of disease 1458 346 23.6 

Fifth day of disease 1912 671 35.0 

It will be seen by the foregoing table that early treatment influences 
the pi'ogno.si.s very favorably. 

Complications and Sequelae of Diphtheria. — Adenopathy. — Swelling 
of the lymphatic glands in the region of the local diphtheritic lesion is 
the rule. The cervical glands and the tonsils are accordingly most com- 
monly affected. After these come the bronchial, the intestinal, and the 
mesenteric glands. 

In the pure diphtheria, i. e., the simple fibrinous type, the glands are 
swollen, slightly tender, and freely movable in the surrounding tissue. 

In the mixed forms of infection there is greater swelling and tenderness, 
the glands being lost to the touch in the surrounding swollen and infiltrated 
tissue. In some cases the swelling is enormous, constituting the symp- 
toms known as "le con proconsulair." Suppuration occurs only 
occasionally, and then only in the mixed type. In the septic type 
gangrenous sloughing may occur. Treatment often results in recovery 
from even severe diphtheritic adenopathy. 

Gastro-intestinal. — Vomiting, loss of appetite, diarrhea, and diphtheria 
of the esophagus and the stomach sometimes occur. 

Urine. — The urine is variable in quantity and chemical proportions. 
Probably one-half of all cases of diphtheria are albuminuric, the toxic 
varieties having albumin present in nearly all cases. The albuminuria 
is generally due to degenerative changes in the kidneys. Hyaline, 
granular, and epithelial casts may be found. 

"In diphtheria a well-marked increase is the rule, and with the excep- 
tion of very mild or extremely severe cases, of constant occurrence. It 
is interesting to note that, barring a temporary diminution immediately 
after the injection, the leukocytosis is nowise influenced by the antitoxin 
treatment." (Simon.) 

Hyperleukocytosis. — ^This exists in nearly all cases, depending upon 
the toxemia and the sepsis present. It may be so pronounced as to 
constitute a true leukemia. 

Heart Lesions. — Endocarditis, myocarditis, waxy degeneration, nerve 
degeneration, heart clots, and dilatation have been found in some certain 
cases examined postmortem. 

Nervous Affections. — Degeneration of nerve tissue, paralysis, lessened 
functional activity, etc., sometimes attend, but more often follow, an 
attack of diphtheria. 

Postdiphtheritic Paralysis. — Postdiphtheritic paralysis usually affects 
the velum palati (benign and discrete form) and the pharynx. The 
chief symptom present is difficulty in swallowing and the return of 
liquids through the nose. Each act of swallowing is accompanied by a 
laryngeal cough. The voice is nasal, articulation very much interfered 



DIPHTHERIA 461 

with, and the patient snores during sleep. The paralysis disappears 
in from one to three weeks. 

In the general or diffused postdiphtheritic paralysis the palatal and the 
neighboring muscles are involved. The muscles of the eye are most 
frequently affected. Unequal pupils, diplopia, strabismus or ptosis 
may be present. Complete recovery eventually takes place. The 
patellar reflex is impaired, or lost, and the muscles of the feet may be 
paralyzed. The patients shuffle their feet on the floor in walking. 
"Diphtheritic pseudotabes," or even complete paralysis of the lower 
extremities, may complicate some cases. The muscles of the upper 
extremities are less often affected. The muscles of the neck and the 
head are rarely involved. If they are, the child's head falls over on his 
shoulder. The facial expression may be lost, giving an idiotic cast to 
the countenance. 

Diaphragmatic paralysis occurs in about 7 per cent, of cases, and may 
lead to a fatal termination. The chief sign of diaphragmatic paralysis 
is a sinking in of the abdomen during inspiration, and distention during 
expiration. Respiration is rapid and panting. Bronchitis or other 
slight lesion of the lower respiratory tubes may lead to asphyxiation and 
death. 

Cardiac or Vagus Paralysis complicates about 1 per cent, of the cases. 

Skin. — Erythema, papular eruption, brownish discolorations, and 
measles and scarlet-fever-like eruptions of the skin may complicate the 
disease. 

Bronchopneumonia. — ^This is a serious complication, often causing 
death after tracheotomy and intubation. It is ushered in by a rise in 
temperature, increased cyanosis (in laryngeal cases), change of the 
respiration-pulse ratio from normal 1.4 to 1.3. At first the physical 
signs are those of diffuse bronchitis, later of consolidation over several 
areas. 

Prophylaxis. — The following rules should be observed in preventing 
the spread of diphtheria. (Abstracted from the Rules of the Health 
Department, City of New York.) 

1. No one but the attendant and the physician should be permitted 
to enter the sick chamber. 

2. The discharge from the nose and the mouth should be received on 
cloths provided for the purpose, and immersed for two or three hours in 
a solution composed of six ounces of carbolic acid dissolved in one to 
two gallons of hot water, and then boiled in soap-suds for one hour. 
All bed and personal clothing used about the patient should be similarly 
treated inside the sick room. 

3. The hands of the attendant and the physician should be washed 
in the same carbolic acid solution, and washed in soap-suds after making 
a])j)lications or handling the patient, and before eating. 

4. Surfaces soiled by discharges should at once be flooded with carbolic 
acid solution. 

5. Table utensils used by the patient should be kept in the sick room, 
for his especial use, and should be washed in carbolic acid solution and 



462 DISEASES OF THE LARYNX 

then ill hot soap-suds. The soap-suds vessel should then be washed in 
the carl)olic acid solution. 

0. The sick room should be aired two or three times daily, and swept 
frequently after scattering sawdust, wet tea-leaves, etc., on the floor 
to prevent the (hist from rising. The furniture and the woodwork should 
be wiped with damp cloths. The sweepings should be burned, and the 
cloths soaked in the carbolic acid solution. 

7. All unnecessary articles of furniture, pictures, draperies, clothing, 
etc., should be removed from the room as soon as the nature of the malady 
is recognized. 

8. "When the patient has recovered, he should receive a hot soapsuds 
bath, including his hair, clean clothes put on, and be removed from the 
sick room. He should be kept in quarantine as long as cultures of the 
dij)htheria germ can be obtained from his throat. 

In addition to the rules given in regard to the patient and the sick 
room, the physician and the nurses should protect their clothing by 
wearing long gowns, which should be kept just outside the patient's 
room. 

9. They should also be given immunizing doses of antitoxin, 

10. The room should be scrubbed with bichloride of mercury solution, 
1 to 1000, all over, woodwork repainted or varnished, walls cleaned and 
repapered, and the furniture sterilized with formaldehyde vapor, or, 
in the case of upholstered furniture, disinfection is better done by steam. 

11. The periodical inspection of public schools by a corps of physicians 
will do much toward limiting the spread of the disease. 

Immunization by Antitoxin. — ^An immunizing dose of antitoxin ranges 
from 100 to 500 units, according to the age of the patient and the length 
of time immunity is desired. In an average case 100 units will be 
effective for ten days, while 500 units will be so for twenty-eight days. 

Treatment of Diphtheria. — The treatment may be divided into (1) 
local, (2) general, and (3) measures for the relief of the suffocation. 

Local Treatment. — This consists in the use of an antiseptic solution, 
such as l)oracic acid, chloride of sodium, etc., at a temperature of 110°, 
with a fountain syringe. The patient should be wrapped tightly in a 
sheet fixed with safety pins. He should be placed upon his side and the 
glass or hard-rubber nozzle of the syringe applied to one nostril, the fluid 
flowing out at the other, until it comes forth clean. The patient's mouth 
should be held open with a spool or a mouth gag to prevent swallowing, 
as this act might force the solution into the middle ears and cause infec- 
tion and mastoiditis. The pharynx should be treated in a similar man- 
ner. If it is desirable to combat pain and swelling, the solution should 
be about 130° The irrigations may be repeated at intervals of six 
hours. 

General Treatment. — The general treatment of diphtheria consists in 
the administration of stimulants to overcome the depression, the weak 
heart's action, the irregular pidse, and the septic condition. Alcohol, 
in the form of whisky or brandy, is the best for this purpose, and should 
be given to an infant in 10 to 15 drop doses, well diluted with water. 



DIPHTHERIA 463 

three or four times a day. A child of three or four years may be given 
an ounce in twenty-four hours. In septic cases much more can and should 
be given. Strychnine is the second best stimulant. Dose, child one 
year old, j^-^ grain every two or three hours. Child three to four years 
old, gig- grain every two or three hours. 

Sedatives should be given to relieve restlessness, cough, and spasm 
(second stage) in laryngeal cases. Morphine in -^-q to -^2 gr. doses. Emetics 
may be given to overcome spasms and to remove mucus in the laryngeal 
cases. 

Antitoxin in Diphtheria. — The value of antitoxin is shown by a compari- 
son of the following tables: 

Table I. — By Briggs and Guerard. 

Treated with antitoxin. Mortality. 

Ages. Cases. Deaths. Per cent. 

0-2 years 1494 469 31 . 4 

2-5 years 3678 762 20.7 

5-10 years 3184 473 14.8 

Over 10 years 1444 99 6.0 



Table II. — By Baginsky. 

Not treated with antitoxin. Mortality. 

Ages. Per cent. 

0-2 years 63 . 3 

2-4 years 52.8 

4-6 years 37.9 

6-10 years 24.6 

10-15 years 14.6 

The advantages of the antitoxin over the other methods of treatment 
at the various ages is strikingly shown by a comparison of the foregoing 
tables, and needs no further comment. 

Antitoxin in laryngeal cases is valuable in two ways, namely: (a) It 
prevents many cases coming to the operative stage, and (6) it affects 
favorably the intubated and tracheotomized cases. Statistics go to 
show that it affects the intubated cases more favorably than it does those 
upon which tracheotomy has been performed. 

Antitoxin in relation to paralysis seems to increase it rather than to 
decrease it. This is perhaps explained by the fact that cases treated 
with antitoxin live longer, and thus give more time for it to develop. 
Many more bad cases survive. 

Antitoxin injections often produce a transient albuminuria. 

Dosage and Clinical Administration of Antitoxin. — The following 
dosage is recommended: (a) 2000 to 3000 units in ordinary diphtheria to 
a child over one year old; {h) 3000 to 5000 units in severe laryngeal cases 
of any age; (c) 1500 to 2000 units to an ordinary case in a child under 
one year old. 

Repeat the dose in twelve hours, or less, if the symptoms are increasing, 
and in eighteen to twenty-four hours if there is not decided improvement. 
A third dose may be given, if needed, in twenty-four hours. 



464 



DISEASES OF THE LARYNX 



An ordinary sterilized hypodermic syringe holding 5 c.c. is suitable 
for making the injections. The skin should be cleansed with an anti- 
septic solution. 

Place of Injection. — The skin of the thigh, the posterior axillary line of 
the chest, or the al)donien are favorable locations. 

Effects of Antitoxin on the Pseudomemhrane. — In a few hours after the 
injection it becomes blanched, the dirty color less pronounced, and the 
membrane more granular and swollen. Later it becomes loosened 
around its edges, and rolls up, detaching itself spontaneously or after 
irrigation. If the membrane returns repeat the dose of antitoxin at once. 




The line of incision in upper tracheotomy preparatory to laryngeal fissure or laryngectomy. 



Effects on the Temperature. — In pure or simple diphtheria the tempera- 
ture rapidly returns to the normal, whereas in the mixed cases it comes 
down more slowly. If the temperature does not fall in the regular way, 
a second injection is indicated, provided the temperature cannot be 
accounted for by some complication. 

Indications for Antitoxin. — 1. In mild suspicious pharyngeal, nasal, 
buccal, conjunctival, or cutaneous cases, give antitoxin if the child is 
over one year of age and there is a distinct history of exposure. 



TRACHEOTOMY 



465 



2. In suspicious laryngeal cases give antitoxin at once, and make 
microscopic and culture examinations afterward. 

3. All catarrhal cases require antitoxin. 

4. In pseudodiphtheria, with repeated negative findings as regards 
the Klebs-Loeffler bacillus, antitoxin need not be given. If in doubt, 
however, give it. 

Surgical Treatment. — Tracheotomy. — ^This operation is not now in 
vogue, relatively, as it was in former years. Intubation is usually 
elected in its stead, as it is a safer and surer means of tiding the patient 
over the suffocative period. Nevertheless, there are still cases in which 
tracheotomy is indicated. 

The indications for tracheotomy are: (a) When intubation tubes are 
not available, or if, for any reason, their use is not understood (Northrup) ; 
(6) in excessive edema of the larynx, where the intubation tube does not 
give relief; (c) when the membrane is in the lower tracheal tract, though 
these cases are favorable for tracheotomy. 





Tracheotomy tube. 



Tracheal tube in position. 



r The method of jjerforming tracheotomy now in use is known as the 
high operation, in contradistinction to tracheotome inferieure, as first 
practised by Trousseau. In the low position of Trousseau, the blood- 
vessels passing over the field of operation render the operation difficult. 

High tracheotomy is preferable. It should be done under antiseptic 
precautions, although this is not always practicable, on account of the 
urgency for immediate relief. 

Steps. — (a) The cricoid cartilage should be located with the index 
finger of the left hand, while the larynx is held firmly but lightly between 
the thuml) and the second finger. 

(h) The skin and the subcutaneous tissue should now l)e incised, 
beginning with the location of the tip of the index finger, carrying it 
downward in the median line \ inch to 1 inch (Fig. 273). 

(c) With the tij) of the index finger in the superior angle of the wound, 
30 



466 



DISEASES OF THE LARYXX 



the bistoury should he passed under it into the trachea and the incision 
carried downward in tlie mecHan hne far enough to achiiit the finger into 
the wound. With the finger tluis phiced blood cannot enter the trachea. 
A still better practice is to first check all bleeding with artery forceps or 
ligatures, and then open the trachea. If suffocation is imminent, the 
first method may be adopted. 

(d) The cannida (Figs. 274 and 275) should next be introduced as the 
finger is gradually withdrawn. If necessary, the dilator and the retractors 
may be used. 

(e) The cannula should now be secured in its position by pieces of tape 
passed around the neck. 

(/) If the sufi'ocation is not relieved at once, there is either pseudo- 
membrane still lower down in the trachea — perhaps a detached piece 
over the orifice of the cannula — or the cannula has become filled with 




Dwyer's intubation instruments. 



mucus and shreds of pseudomembrane. In this event the inner cannula 
should be removefl and cleared of mucus, etc. (g) If the removal of the 
inner cannula does not relieve the suffocation, there is probably mem- 
brane low down in the trachea. 

The mishaps or accidents which may attend the operation are: (a) 
Failure to open into the trachea, especially in very fat children; (b) 
hemorrhage where the incision is carried too far to either side or too far 
downward; (c) an irregular or too small incision, making the introduction 
of the cannula difficult; (d,) secondary hemorrhage; (e) asphyxiation 
from dislodged membrane; (/) a too greatly retracted head, thus flatten- 
ing the trachea and causing stenosis. 

The after effects of tracheotomy may be summarized as follows: (a) 
Disappearance of the cyanosis and suffocation; (h) sleep; (c) coughing 
with expulsion of pieces of membrane and mucus through the cannula;, 
(d) slight fever of two to three days' duration. 

The complications which may arise are: (a) Infection of the tracheal 
wound, the bronchi, and the lungs; (6) ulceration of the trachea at the 



TRACHEOTOMY 



467 



tip of the cannula; (c) erysipelas of the wound; (d) and most important 
of all, bronchopneumonia from the second to the seventh day after the 
operation. When this occurs the prognosis is very grave. 

The after-treatment consists in: (a) The removal of the inner cannula 
every two or three hours for cleansing; (b) the external cannula should 
be removed and cleaned every twenty-four hours, the child being placed 
flat on his back as in the operation — the wound should be cleansed 
each time the external cannula is removed; (c) under antitoxin it is not 
probable that the cannula will need to be worn after the third day, 
whereas under the older methods of treatment it was usually worn a 
week or more. 




The index finger of the left hand holding the epiglottis against the base of the tongue 
preparatory to intubation. (After Shurley.) 



The author recently removed the cannula from a child who had worn 
it for four years. It was necessary to first dilate the glottis with curved 
Heryng bougies introduced through the tracheal opening. After a few 
treatments laryngeal respiration was sufficiently restored, and the tube 
was removed. An attempt was afterward made to close the tracheal 
wound, but the anterior wall of the cartilaginous rings of the trachea 
had disappeared from pressure necrosis. The skin, when brought over 
the wound, acted as a valve closing the trachea, asphyxia resulting. 



468 



DISK ASKS OF TJIE LARYNX 



hiiuhation. — To O'Dwyer is due the credit of first practising intubation 
upon his charity patients. The tubes used at that time were straight 
and easily expelled. lieing discouraged by the many obstacles in his 
way, he was almost persuaded to abandon the practice. x\t about this 
time Dr. F. E. Waxam successfully intubated a patient in private prac- 
tice. Dr. O'Dwyer was greatly encouraged by Dr. Waxham's success, 
and improvement in the tubes and instruments for their introduction 
and removal rapidly followed, and, though there was much opposition, 
intubation became one of the recognized therapeutic measures in stenosis 
from laryngeal dij)litlieria. 

Fig. 278 




Tlie tube passiiiK tlirouKli tlie cliiiik of tlie glottis, 
against the base f)f tlie tongue. A stout loop of tinea 
speedy removal in ease sufToeative symptoms follow itf 
engaged in the esophagus. 



le index finger still holding the epiglottis 
is attached to the tube to provide for its 
itrodui'tion, and in case it is accidentally 



The introduction of antitoxin has very greatly reduced the necessity 
for intubation, though there are still many cases in which it is indicated. 

Indications for Intubation. — (o) Pronounced tracheal stenosis, as 
shown by greatly retracted supraclavicular and epigastric areas calls 
for the immediate resort to intubation, even though antitoxin has been 
given and suflicient time has not elapsed for its favorable influence. If 
milder suffocative symptoms are present, and antitoxin has been given, 
intubation may be delayed pending the results of the antitoxin. Since 



INTUBATION 



469 



the use of antitoxin not one-half as many cases come to operation as 
formerly. (6) If the physician is not within easy call, it is safe to intu- 
bate without waiting for pronounced suffocative symptoms. 

Technique of Intubation. — The child is prepared for intubation by 
wrapping it in a sheet or a blanket from the shoulders downward. The 
sheet should be secured with strong safety pins, so as to bind the arms 
and legs of the child. This being done, the nurse should sit upright in a 
chair with the child upon her lap, his head resting against her left breast. 
His legs should be secured between hers, her right hand grasping his 
left, and her left hand his right. The assistant should stand behind 




The tube in position in the larynx. The loop of thread is still attached, as the tube may hav( 
to be removed by the nurse to relieve impending suffocative sjTnptoms. 



the nurse and hold the child's head between his hands, as though sus- 
pending the child from the parietal walls of his cranium. A proper 
sized tube (Fig. 276), threaded with silk through its eyelet, should be 
in readiness. The operator shoukl stand or sit in front of the child, 
introduce the mouth gag, turn it over to the assistant, who holds it 
l)etween his hand and the patient's left cheek while the operator 
introduces the index finger of his left hand and hooks it over the 
epiglottis (Figs. 277 and 278). Then crowding his finger ;is far to 
the left as possible, the intubation tube, on the introducer, is carried 



470 



DISEASES OF THE LARYXX 



into the mouth, closely hugging the centre of the posterior portion of 
the tongue, the handle of the introducer being on the chest of the 
child. As the tip of the tube passes back of the epiglottis under the 
finger of the operator, the handle should be gradually elevated, until 
the tip of the tube is directly over the chink, of the glottis, when it 
should be suddenly lowered, thus passing the tube into the box of the 
larynx, and on downward into the glottis and the trachea. The tip of 
the finger then engages the rim at the head of the tube (Fig. 280), the 
introducer is loosened and removed, and with a gentle pressure the tube 




The removal of the loop of thread, the index finger of the left hand being placed against 
the head of the tube to prevent its displacement. 



is firmly pushed deep into the larynx and the trachea. If, after waiting 
twenty to thirty minutes, the child tolerates the tube, the loop of string 
should be cut (Figs. 279, 280 and 281), the index finger re-introduced 
against the head of the tube, and the string removed. For obvious 
reasons the child should be kept wrapped until the string is removed. 
Fig. 282 shows a false entry of the tube into the esophagus because 
the handle of the introducer was not sufficiently elevated before the 
tube was dropped into the laryngeal box. 

Intubation may also be performed in the dorsal position, the same 
relative positions and steps being observed as in the upright position. 



INTUBATION 



471 



Extubation or the Removal of the Tube. — The removal of the tube 
may be done by observing the same precautions used in intubation, the 
index finger of the left hand guiding the extractor to the opening in the 
tube (Fig. 283). Another method now occasionally used is to leave 
the silk string attached, looping it over the left ear and securing it to 
the cheek with adhesive plaster. The removal of the tube is thereby 
rendered quite easy. It is also easy for the child to remove it, hence this 
is a serious objection to the method. One grain of Dover's powder, or 
tV to iV gr. of morphine, may be given a few minutes before extubation, 
to prevent spasm and re-intubation for its relief. 




The tube in position after the withdrawal of the thread. 



When to Remove the Tube. — Under antitoxin treatment the tube may 
ordinarily, in a child over two years of age, be removed in from three to 
five days. Should the tube l^ecome obstructed, it should be immediately 
removed. 

Complications aiid Difficulties. — (a) If the finger of the operator is 
short and stubby, it may be difficult to introduce the tube beside and 
beneath it. (6) The tube may make a false passage through the ventricles 
of the larynx, (c) The prolonged eft'orts of an awkward or inexperienced 
operator may cause suffocative symptoms, (d) Transient spasm of the 
glottis may cause temporary delay in introducing the tube, (e) The 



472 



DISEASES OF THE LARYNX 



narrowest point throufjh wliicli the tnbe must pass is the cricoid ring, and 
edema or swelhiif^ at this point may give rise to some difficulty in intro- 
ducing it. 

A smaller one may be passed with slight force. The action of the 
tube in being expelled in this condition has been aptly said to "creep 
back like an oiled cork in a l)ottle." (/) Prolonged retention of the 
tube may be nec(\ssary on account of the persistence of the pseudo- 
meml)rane, ulcerations about the cricoid cartilages, traumatisms, cica- 
tricial contractions, etlema, abductor paralysis, or exuberant granulations. 




Making a false passage into the esophagus on account of lowering the handle of the obturator. 
The tip of the tube should be introduced by the side of the finger tip, and the handle of the 
obturator elevated until the tube .stands perpendicularly, and then passed directly <l()wnward 
througii the <-!iink; of the glottis. 



(g) More rarely, the tube may be swallowed (no danger from it). 
(//) The tube may become obstructed by the thread or catgut being 
aspirated into it and swollen by the secretions; even food may obstruct it. 
The Feeding of Iiifitbafed Children. — Most cases take liquid food 
very well in the upright position, although some take it with pain and 
cough. If the upright position is not practical, Casselberry's position 
may be resorted to. It consists in placing the patient (m his back with a 
pillow beneath the shoulders, his head bent downward and backward at 
an angle of 45°, the legs being elevated (Fig. 284). Liquid or semisolid 




The introduction of the obturator for the removal of the tube. The finger is first introduced 
to lift the epiglottis and to guide the tip of the obturator into the intubation tube. 




FeedinK an intubated cliii.l with a nur.sinK bottle. Oasselberry's position. The shouldois are 
raised to allow the liead to assume a lower position tluui the slioiildcrs. 



474 



DISEASES OF THE LARYXX 



food may be given in this position. The child should be allowed to 
swallow several times before assuming the upright position, to remove 
the food from the epipharynx. Ilillis places the patient upon his 
stomach, as shown in Fig. 285. Gavage may be resorted to if the 
pharynx and the larynx are not too swollen and painful. The tube 




Feeding an intubated child th 



a rubber tube by jucti 



should be introduced through the nose and rapidly passed into the 
esophagus. Food being poured into the funnel passes into the eso- 
phagus and the stomach. \Yhen removing the tube, pinch it to prevent 
the liquid passing into the larynx as it comes out. 

Rectal alimentation may be resorted to if feeding by either of the 
foregoing methods is not practicable. 



QHAPTE^ XX VL 

t i !. a 

PACHYDERMIA LARYNGIS. MALFORMATIONS AND DEFORMITIES. 
PROLAPSE OF THE VENTRICLES. STENOSIS. 
SUBGLOTTIC STENOSIS. 

According to Chiari, "the verrucous form of pachydermia is identical 
with the papilloma of the laryngologist, and has no relation to the diffuse 
form. Diffuse pachydermia may be primary, or it may be secondary 
to some other affection of the larynx, such as tubercle or syphilis." 
In Chiari's experience typical pachydermia is a very rare disease. He 
describes the following forms : 

"1. The most frequent and mildest form is a thickening and loosening 
of the epithelium of the interarytenoid fold and the vocal cords, such as 
frequently occurs in chronic catarrhs The treatment is the same as 
for chronic catarrhal laryngitis and consists of inhalations, insufflations, 
applications by means of a brush, and cauterization. The best applica- 
tions are lactic acid and iodine. The nitrate of silver is apt to cause 
increased thickening. Small singer's nodules may disappear under the 
influence of rest and the application of the nitrate of silver in solution 
or in the solid stick. If they are of considerable size, forceps should be 
used to remove them (Fig. 271). 

"2. The typical form of pachydermia laryngis (chorditis nodosa), as it 
affects chiefly the vocal processes, calls for a plan of treatment varying 
according to the circumstances of the case, authors differing greatly 
in their opinions. Some recommend purely expectant treatment and 
avoidance of tobacco, strong drinks, and the abuse of the voice; others 
recommend the internal administration of the iodide of potassium, 
which, though occasionally of some benefit, may also at times produce 
general impairment of health." Chiari recommends the use of electrolysis, 
as employed by Moll, of Arheim, a current of from 10 to 12 milli- 
amperes being used for from three to five minutes at a time. He con- 
siders it the best means of preventing recurrence, though good results 
have also followed operative procedures. 

"3. Large genuine pachydermia growths in the interarytenoid space 
interfere very materially with the voice. Unfortunately, treatment by 
means of cutting forceps, hot or cold snares, etc., do not guarantee free- 
dom from recurrence. 

"4. The last group includes those circumscribed thickenings, out- 
growths, or nodules which accompany tuberculosis, syphilis, chronic 
perichondritis, and perhaps also lupus, which have been referred to as 
secondary or "accessory" pachydermia. The prognosis depends on their 
etiology, as also does the treatment, the latter varying according to the 



476 DISEASES OF THE LAFYXX 

nature of the most distressing symptoms. Xaturally the syphihtic form 
is much more t'avoral)le than the tul)erculous, though not infre(juently 
it resists specific reme(Hes. Operative treatment of the same kind as 
for the typical j)rimarv form is called for in suitable cases; that is, if the 
general health is good and the respiration or voice is not seriously inter- 
fered with by the local disease. The method of treatment which is 
most highly recommended is the use of electrolysis by means of a bipolar 
instrument with a current of from 10 to 15 ma. This causes no reaction, 
and seems to protect against recurrence better than any other treatment. 
"There is no doubt that pachydermia laryngis, whether in the simplest 
form in the interarytenoid space or in the typical form on the processes 
vocalis, is only a symptom of chronic catarrh, and is not to be looked 
upon as a disease in itself." 



MALFORMATIONS AND DEFORMITIES OF THE LARYNX. 

^lalformations of the larynx may be either congenital or acquired. 
But little is known concerning the true cause of congenital malformations, 
only that some paternal disease or taint acts as a predisposing factor. 
Accjuired deformities are the result of postnatal disease. 

Malformations of congenital origin are often associated with arrested 
development of the genitalia. The lungs, the bronchi, and the trachea 
have the same embryological origin (the foregut) as the larynx, hence 
in malformations of the larynx there is also a similar defect in these 
organs. In monstrosities having no larynx the lungs are absent also. 
If the larynx is diminutive the lungs are likewise affected. Of the other 
congenital deformities, webs or bands across the glottis are a common 
form. The w^ebs usually connect the vocal cords at the anterior commis- 
sure, though they are sometimes between the ventricular bands. They 
are of a pale color, but may be differentiated from the vocal cords by their 
position. Sometimes they are fragile and sometimes resilient. The 
perforated diaphragm variety is rare, and is associated with poorly 
developed lungs. Another form consists of clefts in the interarytenoid 
space extending to the palate and the cricoid cartilage. The epi- 
glottis is often deformed by arrested development, the small V-shaped 
e])iglottis of childhood being a common variety. Very small, and total 
absence of the larynx have been reported. 

Ilyperirophij or hyperplasia at the anterior commissure has been 
mentioned as being of congenital origin. 

Larijwjoccle (dilatation of pouches) is due to congenital malformation 
and failure of union in portions of the thyroid cartilage. It is rare in 
man, though common in the lower animals. 

In acquired malformations, erosions from syphilis, tuberculosis, etc., 
may result in the partial destruction of the framework of the larynx, the 
ej>iglottis often also being thus partially destroyed. 

Acquired stenosis (see also Stenosis of the Larynx) may follow trau- 
matism or constitutional causes, as syphilis. These cases are serious 



I 



STENOSIS OF THE LARYNX 477 

on account of the edema and the dyspnea. Tracheotomy or intubation 
may become necessary. Redundant granulations following the pro- 
longed use of the tracheotomy tube caused laryngeal stenosis in one of 
my cases. The child had been tracheotomized four years before he 
came under my care, and upon examination I found him unable to breathe 
through his larynx. The larynx was opened by bougies passed upward 
through the tracheal wound and through the glottis. This procedure 
was done under general anesthesia. 

Hypertrophies or growths, usually of a papillomatous nature, form at 
the anterior commissure in either the single or the multiple variety. 
Microscopically they appear as local hypertrophies of the mucous mem- 
brane, having a stratified epithelial covering, enclosing a core of connec- 
tive tissue with some bloodvessels and a glandular substance near the 
base. Indeed, they are but elevations of the normal tissue. This 
seems to distinguish them from true papilloma. While these papillo- 
matous elevations of the mucous membrane are congenital, mouth- 
breathing, according to Lennox Browne, tends to perpetuate them. 



PROLAPSE OF THE VENTRICLE OF MORGAGNL 

Watson Williams claims there can be no prolapse of the ventricles, 
but that which appears to be a prolapse is, in fact, an infiltration of the 
tissues. This is apparently supported by the fact that nearly all reported 
cases have been either syphilitic or tuberculous. On the other hand the 
tumor-like mass is quite soft to probe pressure, and a number of observers 
have reported successful, though fugitive, replacement of the pouching 
membrane. 

The presence of this condition should arouse suspicion of either 
syphilis or tuberculosis. The treatment by local applications is useless. 
Replacement, followed by cauterizations to excite inflammatory reaction, 
offers some hope of permanent cure. The extirpation of the mass with 
cutting forceps, or by thyrotomy, may be resorted to if simpler measures 
fail. Antisyphilitic remedies should first be tried, however, before 
surgical interference is attempted, unless it becomes necessary to perform 
tracheotomy to relieve suffocative symptoms. 



STENOSIS OF THE LARYNX (MALFORMATIONS OF THE LARYNX). 

Stenosis of the larynx properly comes under malformations, but its 
importance merits separate treatment; hence, the various types of stenosis 
are included in this section, regardless of their relationship to malforma- 
tions. Stenosis arising from constitutional disorders, as syphilis, tuber- 
culosis, and Icpi-osy, each have their peculiarities. 

Syphilitic Stenosis. — TIkm-c are three prominent conditions arising 
in the course of syphih'tic hii'viigitis which may cause laryngeal stenosis, 
namely: 



478 



DISEASES OF THE LARYXX 



(a) Chronic edema. 

(b) Cicatricial contraction or webs. 
(c)|IIyj)er])la.stic or papillary growths. 

(a) Chronic Edema. — Chronic edema is commonly present in syphilitic 
laryngitis, though it does not always seriously occlude the glottis. 
Nevertheless, it presents favorable conditions for the supervention of an 
acute process, which may produce serious stenosis. This is especially 
true in children who inherit a syphilitic taint. Such children are verj^ 
liable to acute edema, which gives rise to symptoms quite like those found 
in croup. Fortunately the infantile cases respond quickly to anti- 
syphilitic remedies. In adults, as well 
Fig. 286 ^s in children, the treatment consists 

in the administration of the iodide of 
potash or iodonucleoid, which often 
reduces the local edema in a short 
time. 

It should be stated that it is the 
tertiary stage of syphilis that results 
in stenosis, hence the treatment should 
be conducted accordingly. 

(b) Webs and Cicatricial Contrac- 
tion. — Webs and cicatricial contrac- 
tion are the most common manifesta- 
tion of syphilitic laryngitis. The webs 
vary in color and thickness. They 
are usually pale, and may be indistin- 
guishable from the cords over which 
they extend. The vocal cords and 
the ventricular bands are usually 
bound together, and the web often 
extends across the chink of the glot- 
tis, especially at the anterior portion (Fig. 286). Lennox Browne cites 
a case in Avhich the epiglottis was bound down by cicatricial adhe- 
sions. 

The voice is hoarse or restricted in its register, while the breathing is 
dyspneic. The degree of the dyspnea depends upon the amount of 
edema and fixation of the cartilages, as w^ell as upon the overlying web 
or cicatricial contraction. When a patient gives a history of recurrent 
attacks of dyspnea extending over several years, it is good presumptive 
evidence that he is suffering from syphilis of the larynx. A spasmodic 
cough, not unlike that in pertussis, is usually present. Pain is not un- 
common. There may be an admixture of syphilis and tul)erculosis, 
which may somewhat obscure the diagnosis. 

((•) Hyperplastic or Papillary Growths. — These usually form near the 
anterior commissure of the glottis, and they may be either single or 
multiple. The treatment should be antisyphilitic and expectant. If 
they ])roduce stenosis, they should be removed with the curved laryngeal 
forceps or the snare, or by laryngofissure. 




L-icatncial webb across the anterior com- 
missure of the vocal cords. 



I 



STENOSIS OF THE LARYNX 479 

Tuberculous Stenosis.— Tuberculosis of the larynx does not often 
close the glottis by cicatricial contraction, as is so frequent in syphilis. 
This is explained by the slight reparative effort following tuberculous 
ulceration. It may produce stenosis by the excessive infiltration of 
the arytenoid cartilages, v^hich may overhang the glottis and occlude the 
respiratory passage. Tuberculous perichondritis and chondritis may 
result in fixation of the arytenoids, and thus prevent abduction of the 
vocal cords. The lumen of the glottis is thereby rendered very narrow, 
and distressing dyspnea results. 

Lupus Stenosis of the Larynx.— This disease in the larynx is char- 
acterized by a cicatricial contraction and matting together of the parts. 
Lupus runs a much more chronic course than active tuberculosis of the 
larynx, hence the greater changes. Virchow says the arytenoids are 
occasionally surrounded by hard papillary growths in the active stage 
of lupus. The scar tissue in lupus is very unyielding and not readily 
absorbed, even under the pressure of laryngeal tubes. 

Leprous Stenosis. — The stenosis rarely occurs until the patient is in 
the last stages of the disease. In this stage it often becomes so pro- 
nounced as to call for tracheotomy to relieve the distressing dyspnea. 

Ventricular Eversion and Stenosis. — ^The eversion of the sacculus 
laryngis is scarcely possible as a primary condition. (See Prolapse of 
the Ventricle of Morgagni.) Anatomically it appears to be too firmly 
adherent to the adjacent tissues to permit of its prolapse. There may 
be a disease of the underlying perichondrium of the laryngeal carti- 
lages predisposing to the eversion and the consequent stenosis. Tumors 
and glandular enlargement may also push the sacculus toward the median 
line and cause stenosis. 

Traumatic Stenosis. — Stenosis of the larynx may be due to the inha- 
lation of hot vapors or to the ingestion of corrosive fluids, as carbolic 
acid. 

Treatment. — The treatment of laryngeal stenosis is both medical 
and surgical. The following table gives a suggestive line of treatment 
in the various conditions causing stenosis : 

Medical Treatment. — (a) In syphilitic edema and infiltration without 
cicatricial contraction the iodides are indicated. Saline laxatives may 
be given with good results. 

(6) Acute edema supervening upon a preexisting fibrous stenosis 
should be treated by the local application of adrenalin and by free saline 
catharsis. 

(c) The edema of tuberculous laryngitis may be relieved by tonic 
remedies and the cautious administration of mild cathartics. 

Surgical Treatment. — (a) Webs of syphilitic origin should be broken 
down by systemic dilatation by means of Schroetter's laryngeal tubes 
(Fig. 287). The larynx should be cocainized, the index finger of the 
left hand introduced through the narrowed chink of the glottis. The web 
will thus bo put upon the stretch, or torn. A larger tube should be 
introduced after leaving the first one in place a few minutes. This 
process should be continued three times a week until the stenosis is 



4S0 DISEASES OF THE LARY.W 

completely overcome. Even then the tubes should he introduced at 
intervals of a few weeks to prevent the reformation of the webs. 

{!)) Cicatricial contraction due to syphilis should be overcome in the 
same manner as described in the preceding paragraph, though the 
dilatations will have to be used more persistently. 

(c) Hyperplastic or papillary growths of syphilitic origin do not always 
yield to the iodides, and should, therefore, by either direct or indirect 
method, be removed with laryngeal forceps under general or cocaine 
anesthesia. Occ-asionally the papillary growths become wedged in the 
chink of the glottis and cause sudden and alarming dyspnea, and necessi- 
tate an emergency tracheotomy. (See Tracheotomy.) 

(d) Tuberculous chondritis and abscess of the larynx, when causing 
stenosis, should be relieved by the removal of the diseased and dislocated 
cartilage with a laryngeal curette or biting forceps. 

Tuberculous ankylosis of the arytenoid cartilages, attended by fixation 
of the cords in adduction with severe dyspnea, calls for tracheotomy 
for the immediate relief of the symptoms, or laryngofissure may be 
necessary at a later time to overcome the ankylosis, or to remove the 
arytenoid cartilages. The abduction of the cords during respiration is 
thus made possible and the distressing dyspnea relieved. 




Schroetter's laryngeal dilator. 

(e) The cicatricial stenosis of lupus should be treated by dilatation 
with Schroetter's tubes, as described in a preceding paragraph, excepting 
that it may require greater persistence. 

(f) Leprous stenosis should be relieved by tracheotomy if the gravity 
of the suffocative fits warrants it. 

(g) Ventricular eversion with stenosis, while secondary to some 
diseased process of the underlying perichondrium, should be overcome 
by removing the prolapsed sacculus membrane with a snare under cocaine 
anesthesia. Failing in this, tracheotomy may be performed, and the 
everted mass removed subsequently by laryngofissure. (See Laryngo- 
fissure.) 

Subglottic Stenosis. — Sajous pointed out that the subglottic space has 
not received the attention which its importance as an inherent portion 
of the larynx warrants. He urges systemic examination of this space 
in all laryngeal cases. The forms of stenosis peculiar to the lower sub- 
glottic region present features of unusual danger and symptoms likely 
to be ascribed to syphilitic disease. Inasmuch as the iodide of potassium 
greatly increases the danger in subglottic stenosis, it should not be 
administered in a case presenting dyspnea as a symptom, unless the 



STENOSIS OF THE LARYNX 481 

non-existence of this condition is determined by infralaryngoscopical 
examination, or the causative disease is clearly recognized as being 
independent of the respiratory tract. He advised that preliminary 
tracheotomy be performed when the iodide of potassium is to be admin- 
istered during the existence of advanced subglottic stenosis. 

Massei states that the subglottic space is the most frequent seat of 
syphilis, tuberculosis, tumors, rhinoscleroma, and foreign bodies. 
Slight syphilitic stenosis is frequently curable without local treatment 
by the administration of sublimate injections with or without the iodides. 
In simple inflammatory and neoplastic stenosis, intubation ofi^ers the 
best results. He agrees with Sajous that too great dependence is placed 
in general antisyphilitic treatment in severe stenosis, and that such a 
course may be fatal. 



31 



CHAPTER XXVIL 

XErROSES OE THE LARYNX. 

NEUROSES OF MOTION. 

Tni-: classification of ,1. Solis-Cohcn is as follows: 
Neuroses of the Motor Nerves of the Larynx. — The motor neurose.s 
are divideil into two groups: 

1. Spasms of the larvnx, or hyperkinesis, /. e., excessive motion. 

2. Taralysis of the larvnx, or akinesis, i.e., absence of motion. 
Spasms of the Larynx. — Spasms of the larynx may be due to 

irritation of the central brain cells in which all the intrinsic muscles are 
thrown into violent action, or to irregidar nervous impulses sent out from 
the motor centres of the brain, causing incoordination of the laryngeal 
muscles. 

Paralysis of the intrinsic laryngeal muscles may be limited to one 
muscle or to a group of muscles, or it may affect all of them. 

The spasms may be either tonic or clonic. 

Tonic spasms are (a) of central origin; (6) from irritation of the trunk 
of the recurrent laryngeal; and (c) from reflex irritation. 

(a) Tonic Spasms of Central Origin. — In tabes dorsalis spasm of the 
adductors of the larynx occurs. The clinical picture shows sudden 
dyspnea w'ith loud inspirations, the cords remaining in adduction for a 
variable time. Tt also occurs in tetanus and hydrophobia. 

(/;) Tonic Spasm from Irritation to the Trunk of the Recurrent Laryngeal 
Nerve. — When the injury is transient and slight, the laryngeal spasm is a 
forerunner of paralysis. Aneurysm of the arch of the aorta, cancer of the 
esophagus, ])leuritic adhesion of the apex of the right lung, and tumors 
of the mediastinal glands may cause the irritation. A slight lesion may 
also occur in tabes. 

(c) Tonic Spasms from Reflex Irritation. — These may occur from irrita- 
tion of the larynx, the fauces, and the neighboring parts. In highly sensi- 
tive children irritation in a remote part of the body may cause adduction 
spasms. The latter condition has been described as laryngospasm 
infantum, and is usually due to intestinal irritation, tapeworm, a tight 
prepuce, or constipation. 

Clonic spasms of the laryngeal muscles are always of central origin, 
and they consist of rhythmical inward movements of the cords. The 
condition may last but a few moments, or it may persist for many 
months. The pillars of the fauces are also often affected in a like 
manner. 

Both tonic and clonic spasms may be present in the same case, 



NEUROSES OF MOTION 483 

especially in the depressors of the epiglottis. The diseases most often 
causing clonic spasm of the larynx are syphilis, meningitis, and intra- 
cranial tumors. 

Clinically, spasm of the larynx may be classified as follows (after 
Coakley) : 

(a) Spasm of the adductor muscles (laryngismus stridulus). 

(b) Spasm of the tensor muscles. 

(c) Spasmodic laryngeal cough or laryngeal chorea. 

(a) Laryngismus Stridulus (Adductor Spasm). — Synonyms. — Spasm of 
the larynx; laryngeal spasm; spasm of the abductors of the vocal cords; 
spasm of the glottis; spasmus glottidis; false croup; child-crowing; 
thymic asthma; asthma rachiticum; Miller's asthma. 

Laryngismus stridulus is a spasmodic act of the intrinsic muscles of 
the larynx accompanied by stridor. It is a neurosis, and is not necessarily 
associated with laryngeal disease. It is not a disease, but a symptom. 
While it is not a disease, it is a symptom causing great alarm. It is often 
associated with laryngeal or tracheal diseases, though it may be a reflex 
phenomenon from irritation in either contiguous or remote organs. It is 
sometimes a symptom of acute laryngitis, pseudomembranous croup, and 
diphtheritic croup, especially in children. It may also occur in non- 
inflammatory diseases of the larynx. It is common in children, but 
rather rare in adults. It is sometimes associated with intestinal disorders, 
as indigestion, worms, and constipation. Uterine disorders and sexual 
excesses have been known to produce it. Disorders of the contiguous 
organs, as the lingual tonsils, the teeth (dentition), elongated uvula, and 
inflamed tonsils, sometimes excite the spasm. The irritation of the 
fauces with a brush, or a foreign body in the pharynx sometimes causes 
the symptom to appear. Cases have been reported in which the pressure 
from an enlarged thymus gland caused laryngismus stridulus. Cerebral 
irritation, caries of the vertebrae, and rickets are known causes. Laryn- 
gismus stridulus appears in the laryngeal crises of tabes. 

Treatment. — The treatment consists in relieving the source of the 
iiTitation rather than in applications to the larynx. For the immediate 
relief from the suffocative spasm the application of cold water to the chest 
or hot water to the nape of the neck should be made. If suffocation 
seems imminent and the lower jaw is relaxed, seize the tongue between 
the thumb and the forefinger and exert traction about every three seconds, 
to excite the respiratory centre through the reflex action of the phrenic 
nerve. If the jaw is set, the same result can be accomplished by exerting 
pressure with the fingers inider the angles of the jaw. Should these 
measures fail, resort to intu])ation or traclieotomy. 

(/;) Spasm of the Tensor Muscles of the Vocal Cords; Aphonia Spastica; 
Phonatory Spasms. — Spasm of the tensor muscles is essentially a neurosis 
from overuse of the voice. The muscles are fatigued and fail to respond 
to the nervous stimulus sent out from the motor centres of the brain; 
they are tired and irritated by a local accumulation of the toxins 
from faulty nu'(iil)()lisiii. Writci-'s and telcgi'aplier's cramp are similar 
affections. 



484 DISEASES OF THE LARYNX 

Symptoms.— Spasm, of the tensor muscles is characterized by sudden 
onset at any moment during speech. It may come on at the beginning 
or in the midst of a sentence. I have seen cases in which the speech 
was suddenly almost or entirely lost for some minutes, after which it 
would quickly clear up and remain so for an indefinite period. The 
patient complains of a rough, harsh feeling in the larynx, accompanied by 
the spontaneous flow of a few tears and slight congestion of the con- 
junctivae. A drink of water hastens the cessation of the spasms. The 
cords are tense and approximated in the median line. 

Treatment. — ^The cases seen by the author have been mild, and occurred 
only at long intervals. They required no special treatment other than 
a few minutes' rest of the voice and a drink of cold water. 

In severe and oft-recurring spastic aphonia prolonged rest of the 
voice is necessary. Such cases are usually overtaxed, or are affected 
by a slight general debility, and they should, in addition to prolonged 
rest away from the persons with whom they are daily associated, be given 
tonic or specific remedies to correct the debility or the specific diseases 
with which each is affected. To this end iron, strychnine, arsenic, 
cathartics, iodide of potash, eggs, milk, etc., should be given. 

(c) Spasmodic Laryngeal Cough or Laryngeal Chorea. — This condition 
is c|uite similar to chorea in other parts of the body, though it is not 
usually associated with it. There are, however, synchronous contractions 
of other respiratory muscles which furnish the blast of air back of the 
cough. The choreic cough occurs at frequent intervals, and is a dry, 
noisy, respiratory explosion resembling the yelp or bark of a dog. It 
occurs most often in females at about the age of puberty, or at the age of 
greatest instability of the nervous system. They rarely occur during 
sleep. Between the intervals the voice is clear. The vocal cords appear 
normal and are closely approximated during the attacks. 

Treatmcni. — The cough is due to an hysterical temperament or to an 
imbalance of the nervous system at or about the age of puberty, and little 
can be done to improve it. A sea voyage or an outdoor life will add 
tone to the system, and thus tend to check the recurrence of the attacks. 
Tonics and sedatives may also be administered. The child should be 
taken from school and sent to the country, or in some way kept outdoors. 
Fresh air and sunshine will do more for these cases than any other 
mode of treatment. 



NEURALGIA OF THE LARYNX. 

True neuralgia is rare, and is characterized by pain without a visible 
cause. Similar pain may be caused by malaria, gout, rheumatism, 
pressure from some tumor or swelling, epipharyngitis, and angina of 
the pharynx. It is obvious, therefore, that the foregoing diseases 
should be excluded before making a diagnosis of neuralgia. 

Treatment. — The treatment of a true neuralgia is successfully accom- 
plished with phenacetin, gr. v to x, every three hours, also with cannabis 



LARYNGEAL APOPLEXY 485 

indica, aconite, and morphine, pushed to their physiological effects. 
While cocaine sprayed into the throat affords immediate relief, it is not 
to be recommended, as these patients easily acquire the cocaine habit. 
Menthol affords relief. Cold or hot applications to the neck also prove 
grateful to these patients. 

If the pain is due to gout, rheumatism, malaria, or pressure of a tumor 
or a gland, treatment appropriate to these conditions should be instituted, 

MOGIPHONIA. 

Mogiphonia is characterized by a difficulty in maintaining the tension 
of the vocal cords while singing, or during forced accentuated speaking. 
In ordinary conversation no difficulty is experienced. 

Treatment. — The treatment is rest. Overtaxation being the cause, 
other forms of treatment are scarcely indicated, unless the condition 
has recurred often and at frequent intervals. When this is the case, tonics, 
massage, cathartics, and eliminative treatment should also be used. 

NERVOUS COUGH. 

This is a spasmodic, croupy, or even musical laryngeal cough, for which 
no physical cause can usually be assigned. It is peculiar to neurotic 
individuals who present other stigmata of a neurosis. It is a "daytime" 
cough, entirely subsiding during sleep, to return the following morning, 
often with increased severity. It often occurs in the hysterical. It may 
be a reflex disturbance from a hypersensitive area in the nose, the epi- 
pharynx, or the chest, hence a careful examination of these parts should 
l3e made. The sensitive areas in the nose and the epipharynx may be 
located by gentle probe pressure without the use of cocaine. In the nose 
Jacobson's tubercle near the anterior end of the middle turbinated body 
may be the seat of the sensitive area. When this is touched with the 
probe it will give rise to the peculiar nervous cough, provided, of course, 
that it is the source of the reflex. Impacted cerumen in the external 
auditory meatus may cause it. The reflex may also have its origin in 
the gastro-intestinal tract. 

Treatment. — ^As most cases are due to a true neurosis rather than to 
some physical lesion, the treatment must be of a tonic and sedative 
character. Sprays of iced lime-water, or menthol in combination with 
camphor, gr. ij to an ounce of liquid petrolatum, etc., may be used to 
relieve the laryngeal irritations. Antispasmodics and sedatives, as 
aconite, cannabis indica, and the bromides may be given internally to 
allay the spasms and the local irritation. 

LARYNGEAL APOPLEXY. 

Synonyms. — Laryngeal vertigo; laryngeal syncope; bronchial syncope; 
complete glottic spasm in the adult. 



486 DISEASES OF THE LARYXX 

Laryngeal apoplexy is characterized by a transient irritation and 
])urning sensation in the lower part of the throat, followed by a fit of 
coughing, dimness of vision, dizziness, and unconsciousness, the patient 
falling to the floor. The face may be congested or pale. 

The disease is a neurosis affecting the coordination of the respiratory 
centres and the nerves of the larynx. It is rare. The attacks may 
last but a few seconds, when the spasms cease and the mind becomes 
clear again. They may recur at intervals of a few weeks. 

Etiology. — The disease is chiefly found among the well-to-do and those 
leading sedentary lives, though one case is reported as occurring in a sailor 
(Whalan). Getchell reported 77 cases ranging in age from seventeen to 
seventy-seven years. iVU but four were males. Rheumatism and gout 
are occasionally associated with it. Neurasthenia is a pretty constant 
factor. Local inflammatory disease of the bronchi, the pharynx, and 
the lar^mx is commonly present, and may be an important causative 
agent. Lennox Browne reported 3 cases in which there was varix at the 
base of the tongue. 

Among the exciting causes may be named worry from strenuous 
business or social conditions, and either physical or mental overwork. 
A pinch of snufiF or other irritating substance inhaled into the larynx and 
the bronchi may bring on an attack. 

Symptoms. — The face is usually flushed, though it may be pale. 
A deep breath is taken, followed by laryngeal spasm. There may be 
epileptiform convulsions, and the sequence ends in a few moments 
by a return to consciousness. After the attack all signs of the disease 
disappear. The disease is clinically like apoplexy with a laryngeal 
aura and laryngeal spasm, the latter being continued long enough to 
produce unconsciousness. Such spasms are liable to occur in neuras- 
thenia and in tabes. Other signs of neurasthenia, epilepsy, and tabes 
should be sought for before pronouncing the case one of laryngeal 
apoplexy. 

Treatment. — The treatment should be addressed to the correction of 
alimentary and hepatic disorders, and to the regulation of the excretory 
organs of the body. Tonics and antispasmodics may be given to tone 
and tranquillize the nervous system. Local lesions, if present, should 
receive appropriate treatment. For instance, bronchitis is the most 
common concomitant disease, and possibly has something to do with 
its causation. It should therefore be treated by the administration of 
4 grains of iodide of potassium in a glass of water after each meal for 
several weeks or months. By relieving the associated diseases of the 
upper respiratory tract the laryngeal spasms and the syncope are some- 
times entirely relieved. 



PARALYSES OF THE INTRINSIC MUSCLES OF THE LARYNX. 

It is difficult to make a classification of the paralyses of the laryngeal 
muscles in such a way as to have it coincide with clinical observation. 



PARALYSIS OF THE INTRINSIC MUSCLES OF THE LARYNX 487 

The intrinsic muscles are supplied by branches of the right and the left 
pneumogastric or vagus nerves. It will be remembered that these 
nerves have their origin near the median furrow beneath the floor of 
the fourth ventricle. Two motor branches, the superior laryngeal and 
the recurrent or inferior laryngeal, are given off from each vagus to the 
larynx. The superior laryngeal also supplies sensation to the whole 
laryngeal mucous membrane. 

Fig. 288 




Schema of the nerve supply of the intrinsic muscles of the larynx. P, the pneumogastric 
nerve; R, recurrent laryngeal nerve; S.L., superior laryngeal nerve; A.C., arytenoid cartilages; 
T, thyroid cartilage; C, cricoid cartilage; A, interarytenoideus muscle; C.A.P., crico-aryten- 
oideus posticus muscle; C.A.L., crico-arytenoideus lateralis muscle; T.A.I., cricothyroidei interni 
muscles. 



By reference to Fig. 288 it will be seen that the superior laryngeal 
supplies only one pair of the intrinsic muscles of the larynx, the crico- 
thyroidei. These muscles are tensors of the vocal cords, hence the wavy 
outline of the cords (Fig. 289) in superior laryngeal paralysis. 

The recurrent or inferior laryngeal nerves supply all the other intrinsic 
muscles of the larynx, namely, the arytenoideus, the crico-arytenoidei 
postici, the crico-arytenoidei laterales, and the internal tensors of the 
vocal cords. 

If the lesion involves all tlir fibers of the left recurrent laryngeal nerve, 



488 



DISEASES OF THE LARYNX 



Fig. 289 



there is total paralysis of all the muscles of the left side of the larynx 
except the cricothyroideus (external tensor). The same is true of the 
right side (Fig. 289). If the lesion involves only a small branch of 
the left recurrent, one muscle alone may be involved, say the crico- 
arytenoideus posticus. This muscle is an adductor, hence there would 
be incomplete closure of the anterior two-thirds of the vocal cord on 
the left side, while the opposite cord would slightly encroach beyond 
the median line. The adduction of the posterior third is controlled by 
the arytenoideus, hence, this muscle being unaffected, closure in that 
region is complete. Single muscles are rarely affected except in diph- 
theria and other local inflammations of the larynx, and in hysteria. 
It is always a question when a single muscle is affected, excepting one of 
the cricothyroidei, as to whether the lesion is in a nerve twig or in the 
muscle itself. Inflammatory infiltration may inhibit the nerve twig 
supplying a certain muscle, or the infiltra- 
tion may cause a mechanical barrier to the 
proper motion of the muscle. Hysterical 
paralysis is, of course, not a true paralysis. 
Paralysis of involuntary muscles usually 
has its origin in a lesion of the medulla 
oblongata or the spinal cord. Lesions of 
the cerebral cortex, on the other hand, 
cause central paralysis of voluntary motion. 
In making a diagnosis in this class of cases, 
aphasia must be distinctly separated from 
aphonia; the same is true in considering 
the etiology. Kraus, in 1884, demonstrated 
that stimulation of the gyrus prefrontalis in 
the lower animals produced a contraction, 
or muscular movements, of the larynx, the 
pharynx, and the palate. Semon and 
Horsley fully substantiated the findings of Kraus by a long series of 
experiments on the lower animals. 

Irritation of one of the external borders of the restiform bodies 
produces unilateral adduction of the vocal cords. Bulbar lesions usually 
produce unilateral paralysis, but many cases of unilateral paralysis are 
also caused by lesions in the medulla. 

Laryngeal paralyses are seldom brought about by tumors of the medulla 
or the pons. Gottstein thoroughly reviewed this aspect of the question, 
and refers to several cases of glioma and one of aneurysm of the basilar 
artery. A bulbar lesion causing laryngeal paralysis usually involves 
the dorsal motor nucleus of the penumogastric, which lies near the 
median furrow, and is beneath the floor of the fourth ventricle.* In 




Paralysis of the cricothyroidei. 
Tlie only muscles of the larynx sup- 
plied by the superior laryngeal. All 
the other intrinsic muscles of the 
larynx are supplied by the recur- 
rent laryngeal nerves. 



• Edinger, Anatomy of Central Nervous System of Man, English translation from fifth German 
edition, p. 375, says: 

"We have learned, then, two nuclei for the vagus, a ventral one, which from its position (in 
the prolongation of the ventral horn) and from the appearance of its cells (multipolar with 
axis cylinders passing directly into the nerve) is motor; and a dorsal one, which, lying in the 
prolongation of the gray matter of the base of tlie posterior horn, is also by its structure char- 
acterized as aenaory." 



PARALYSIS OF THE SUPERIOR LARYNGEAL NERVE 489 

laryngeal paralysis the abductors are usually the first, perhaps the only, 
muscles affected as a result of a central or a peripheral lesion, while in 
hysterical aphonia the adductors are affected. 

Tumors, traumatisms, and other lesions at the base of the skull give 
rise to laryngeal paralysis by implicating the trunks of the pneumo- 
gastrics. It is often difficult to differentiate these conditions from bulbar 
lesions, as they frequently involve the facial, the glossopharyngeal, the 
acusticus, the spinal accessory, also other branches of the pneumogastrics 
beside the laryngeals, depending upon the extent of the lesion. The 
portion of the pneumogastric which lies in the neck (usually the trunk 
and the recurrent laryngeal after it winds around the large vessels in the 
thorax, travelling back along the esophagus to the larynx) is very often 
the seat of the lesion causing the laryngeal paralysis. Among the lesions 
in this locality causing paralysis of the nerves just mentioned are en- 
larged glands, traumatisms due to wounds in operating, goitres, aneu- 
rysms, mediastinal tumors, tumors of the esophagus and the pharynx, 
pleurisy, scoliosis of the cervical vertebrae, tuberculosis of the apices of 
the lungs, and even pericarditis. 

Laryngeal paralysis may be the very first, and for a long time the only 
significant indication of an aneurysm of the arch of the aorta. Often 
no palpable reason for the paralysis can be ascertained, and then recourse 
must be had to a tentative diagnosis of a simple neuritis. The rare 
cases of paralysis of individual muscles must be ascribed to lesions of 
their respective nerve twigs, or to an involvement of the muscular 
structure itself. Paralysis of the abductors is now and then due to trau- 
matism by the passage of a bolus of food through the lower pharynx into 
the esophagus, or even to exposure to cold drinks, as the location of the 
muscles is very superficial. In paralysis of the pneumogastric due to a 
bulbar lesion the involvement of other nerves readily establishes the 
diagnosis. However, an injury to the base of the skull may simulate a 
bulbar lesion by implicating several nerve trunks in addition to the 
pneumogastric. Jackson, Proust, Senator, and Eisenlohr have reported 
cases of bilateral paralysis as being due to bulbar lesions, though they 
are comparatively rare. There is no authenticated case of paralysis 
of the adductors alone from an essential lesion. Occasionally a bulbar 
lesion produces bilateral paralysis, in which instance the abductors alone 
are usually involved; more often the paralysis is unilateral, though not 
so often as when due to other lesions. 



PARALYSIS FROM DISEASE OR INJURY OF THE SUPERIOR 

LARYNGEAL NERVE; PARALYSIS OF THE EXTERNAL 

TENSORS OF THE VOCAL CORDS. 

So far the only lesions which have been noted as causing paralysis 
of the cricothyroid muscles are diphtheria, enlarged glands, and in- 
flammation of the areolar tissue beneatli the angle of the jaw. Typhoid 
fever may cause it. Paralysis of these muscles is extremely rare. 



490 DISEASES OF THE LARYXX 

Symptoms. — Anesthesia of tiie larynx, the phenomenon which was 
clescril)e»l under neuroses of the hirvnx, is a prominent and significant 
symptom. The anestliesia is explained by the fact that it is the superior 
laryngeal nerve, a branch of the pneumogastric, which is affected. 
This branch supplies the cricothyroid muscles with motor stimulus, and 
the whole of the mucosa with sensation. Whenever, therefore, there is 
anesthesia of the whole mucosa of the larynx, the lesion involves the 
superior laryngeal nerve fibers, either after they leave the pneumogastric 
or higher up in the pneumogastric itself. A low-pitched voice and 
inability to sing high tones is characteristic of this affection. When the 
thyro-epiglottic and the aryteno-epiglottic muscles are paralyzed the 
epiglottis stands upright, hence the larynx cannot be closed. Because 
of this and the attending anesthesia, food often finds its way into the 
larynx and upper respiratory tract. No warning is given the patient 
until the food reaches an area below the vocal cords. Hence, pneumonia 
is frequently a serious sequence. Complete bilateral paralysis of the 
cricothyroid muscles is manifested by the peculiar wavy outlines of the 
vocal cords (Fig. 289). According to E. MacKenzie, when this paralysis 
is unilateral the laryngoscope shows one vocal cord on a higher plane 
than the other. 

Diagnosis. — The peculiar wavy outline of the vocal cords and the 
local anesthesia clear up the diagnosis as to the hoarseness and aphonia, 
and distinguish it as a true motor paralysis rather than a neurosis or an 
infiammatory disease. 

Prognosis. — It is very bad if there is a complete bilateral paralysis, 
but not so very grave when only one cord is implicated. The patient 
may succumb to inanition or pneumonia. Lobar pneumonia is the 
usual type, and cases have been recorded where death from this disease 
could only be ascribed to the passage of food or other foreign substance 
into the trachea because of the anesthesia. The prognosis is very bad 
if the recurrent laryngeal nerve is involved at the same time. 

Treatment. — Nourishment by the esophageal tube, galvanism, 
strychnine, and general tonics are indicated. 



PARALYSES OF THE RECURRENT OR INFERIOR LARYNGEAL 
BRANCH OF THE PNEUMOGASTRIC NERVE. 

All the intrinsic muscles of the larynx except the cricothyroidei are 
supplied with motor stimulus by the recurrent laryngeal nerves. The 
crico-arytenoidei postici are abductors of the vocal cords and therefore 
muscles of respiration, in a sense, also, of phonation, as their action is 
necessary to maintain the required equilil)rium of the other muscles in 
this act and in modulating the voice. 

The recurrent laryngeal supplies motor stimulus to the following 
muscles: 



[ 




PARALYSIS OF BOTH RECURRENT LARYNGEAL NERVES 491 

f Crico-arytenoidei laterales (abductor). 
Recurrent laryngeal J Arytenoideus (adductor), 
(inferior laryngeal) j Crico-arytenoidei postici (adductor), 
l^ Thyro-arytenoidei (internal tensor). 

The superior laryngeal nerve supplies the cricothyroidei (external 
tensors) . 

It is clear, from the above analysis, that the recurrent laryngeal nerve 
is the chief motor supply to the larynx, and that it presides over both ad- 
duction and abduction of the vocal cords. It 
is obvious, therefore, that when all the fibers yig. 290 

of the main trunks of the recurrents are 
affected there is total paralysis of both the 
adductor and the abductor muscles of the 
larynx. The only intrinsic muscles of the 
larynx not affected are the external tensors, 
the cricothyroidei, which are supplied by the 
superior laryngeal nerves. These play so 
small a part in the general movements of the 

cords that their action under these circum- Larynx in quiet breathing and 
stances is practically nil. The cords, there- t^e cadaveric position. 

fore, assume the so-called cadaveric position 

(Fig. 290). In studying the various paralyses of the recurrent laryn- 
geals I shall first speak of total paralysis, and follow with the partial 
paralyses. I mean by the term partial paralysis, the paralysis of cer- 
tain groups of muscles rather than an incomplete paralysis of part or 
all of the muscles of the larynx. 

COMPLETE PARALYSIS OF BOTH RECURRENT LARYNGEAL 
NERVES. 

Etiology. — By reference to Fig. 291 the course and distribution of 
the right and the left recurrent laryngeal branches from the pneumo- 
gastrics is illustrated in diagrammatic form. The left recurrent is given 
off at the level of the transverse portion of the arch of the aorta, and 
passes under it, thence upward in the groove between the trachea and 
the esophagus to the muscles of the larynx. As it reaches the larynx it 
breaks into several twigs, thus supplying motor stimulus to all the 
intrinsic muscles of the left half of the larynx except the cricothyroid, 
which is supplied by the superior laryngeal. The left recurrent nerve is 
the most often affected, on account of its relationship to the arch of the 
aorta and the left subclavian artery. Aneurysm of the transverse portion 
of the arch of the aorta causes compression and neuritis of the left 
recurrent laryngeal, and thus inhibits the motor impulses from reaching 
the left half of the larynx. Unilateral paralysis results. Occasionally 
the aneurysm is so large as to encroach upon the structures on tlie right 
side of the chest, and thus may cause compression and neuritis of the 
right recurrent, in which event the paralysis would be bilateral. 

While tlie right recurrent laryngeal is not so often involved, it is. 



492 



DISEASES OF THE LARYNX 



nevertheless, so situated with reference to the subclavian artery and the 
apex of the right lung as to he somewhat frequently the source of laryn- 
geal paralysis. The right recurrent nerve is given off on the level with 
the subclavian artery, and curves around the latter as it starts upward 
to the larynx. Aneurysm of the subclavian may therefore compress it 
and cause neuritis and consequent laryngeal paralysis of the intrinsic 
muscles of the right half of the larynx. The right recurrent nerve is in 
close proximity to the apex of the right lung, and may become involved 

in pleuritic exudates and adhesions 
Fig. 291 in this region, and thus cause para- 

lysis of the right half of the larynx. 
The mediastinum is frequently 
the seat of malignant or other 
growths which press upon one or 
both of the recurrent nerves. En- 
larged glands of the neck, malig- 
nant tumors of the esophagus, and 
other growths in the neck may 
cause pressure and degeneration of 
one or both pneumogastric nerves, 
and produce unilateral or bilateral 
paralysis of the larynx. Scoliosis, 
goitre, and pericarditis may also 
injure the recurrent nerves. Gum- 
mata are frequently the source of 
the nerve lesion. 

The central lesions causing laryn- 
geal paralysis are in the medulla 
oblongata or the spinal cord. The 
exact location of the pneumogastric 
nuclei seems to be, according to 
Kraus, Semon, and Horsley, in the 
gyrus prefrontalis. Tumors of the 
medulla and the pons rarely cause 
laryngeal paralysis. Aneurysm of 
the basilar artery is a known cause. Bulbar lesions causing laryngeal 
paralysis usually involve the dorsal motor nucleus of the pneumogas- 
tric which lies near the median furrow beneath the floor of the fourth 
ventricle. 

Tumors, traumatisms, and other lesions at the base of the skull give 
rise to laryngeal j)aralysis by implicating the trunks of the pneumo- 
gastric nerves. ItHs often difficult to differentiate these from bulbar 
paralysis, as these conditions often involve the facial, the glossopharyngeal, 
the acusticus, the spinal accessory, or other branches of the pneumo- 
gastric nerve. 

The nerves and their filaments may be completely atrophied. The 
remains of the neurilenuna have been found, but fatty degeneration is the 
most frequent degenerative change. 




Schema showing the relations of the pneu- 
mogastric nerve to the trachea, esophagus, 
vessels of the thorax. Also the recurrent 
laryngeal and superior laryngeal branches and 
their distribution to the intrinsic muscles of the 
larynx. (See Fig. 288.) 



PARALYSIS OF BOTH RECURRENT LARYNGEAL NERVES 493 

Symptoms. — ^The symptoms, whether due to lesion of the pneumo- 
gastric trunk or to the recurrent laryngeal, are very much alike. The 
voice is usually weak and husky. The sensibility of the mucous mem- 
brane is usually unimpaired, unless the lesion of the pneumogastric 
trunk is above the point where the superior laryngeal is given off. If 
both pneumogastric trunks or both recurrent nerves are injured, the voice 
is aphonic, as the cords stand in the cadaveric position. If the recurrent 
on one side only is affected, the vocal cord on that side rests in the cadaveric 
position, while the opposite cord has its normal movements. Indeed, it 
encroaches beyond the median line upon attempted phonation, while 
during deep inspiration it is widely separated from the opposite cord. 
In one-sided paralysis the position of the arytenoid cartilages is char- 
acteristic; the arytenoid cartilage on the unaffected side overlaps the 
opposite arytenoid, and is either anterior or posterior to it. Cough is 
usually absent, and when present is due to an irritation of the trachea by 
pressure of a tumor in the neck or upper mediastinum. The cough is 
like that in aneurysm of the arch of the aorta. I have seen a few cases 
of aneurysmal cough, and they were dry and slightly harsh or brassy. 
One case in particular was free from cough except in public gatherings 
or other places likely to excite the heart's action. Coughing and expector- 
ation are performed with great difficulty in bilateral paralysis. 

Dyspnea is absent in unilateral paralysis, but may be present in bilat- 
eral paralysis in spite of the fact that the cords are separated in the "cada- 
veric" position. In the "cadaveric" position the cords stand midway 
between adduction and complete abduction. They are not as widely 
separated as is usual in inspiration, hence the dyspnea. 

In some cases the paralysis is partial, and the symptoms are, therefore, 
correspondingly modified. I have elsewhere called attention to the fact 
that the abductor twigs are more frequently implicated by pressure than 
the twigs supplying the adductors. 

Diagnosis. — Bilateral abductor paralysis during quiet respiration 
bears a slight resemblance to complete paralysis. The act of phonation, 
however, is attended by the adduction or approximation of the cords, 
which readily distinguishes it from the passivity of the cadaveric position. 

Prognosis. — In view of the serious nature of the causes back of 
complete paralysis of one or both recurrent laryngeal nerves, the prognosis 
is grave. In case it is due to syphilitic gummata or to the pressure 
of enlarged glands, the prognosis under appropriate treatment is good. 
If due to the toxemia of diphtheria or to an acute inflammation, complete 
recovery may occur in a few weeks. 

Treatment. — The treatment depends upon the cause of the paralysis 
and the duration of the symptoms. If enlargement of the thyroid gland 
is the cause, the administration of thyroid extract may diminish the size 
of the tumor and thus relieve the pressure upon the nerve. An operable 
tumor causing pressure upon the trunk of the pneumogastric or the 
recurrent laryngeal nerve should be removed to relieve the pressure. 
If tlie^nerve has imdergone degenerative changes, the improvement may 
be slight or absent; if, however, the nerve is still healthy, the paralysis 



494 DISEASES OF THE LARYXX 

may (li.saj)pear after the operation. In aneurysm of the arch of the aorta 
or of the rifjht subclavian, dependence sliould be placed in the use of 
iodoinicleoid in from 5 to 15 grain doses three times a day. Syphilitic 
gummata may be treated with mercurial inunctions and the internal 
administration of iodonucleoid in doses ranging from 10 to 25 grains 
three times a day; or the iodide of potash 10 to 60 grains three times a day. 
The iodonucleoid is as reliable a drug as the iodide of potash, and has 
the advantage of being tolerated by the most sensitive stomach. It is 
free from potash, having a nucleoid base. It is absorl)ed more readily 
by the blood and rapidly saturates the system with iodine, which is the 
active agent in both the iodide of potash and the iodonucleoid. 

Cialvanism and faradism combined with external massage over the 
laryngeal region may be practised to increase the circulation and nutri- 
tion of the atrophied muscles. Strychnine is also a valuable remedy, as 
it increases the nerve energy and tones the muscles. 

If the paralysis is due to diphtheria or one of the exanthemata, consti- 
tutional remedies, as strychnine, iron, and the bitter tonics, should be given 
to build up the waning and depleted cell energy. Eliminative remedies, 
to stinudate the excretory powers of the intestines, the kidneys, the liver, 
and the skin, should be given to clear the toxins from the blood and the 
lymph. 

Tracheotomy may become necessary in a case of severe dyspnea. 



UNILATERAL PARALYSIS OF THE RECURRENT LARYNGEAL NERVE. 

Etiology. — Unilateral paralysis of one-half of the intrinsic muscles 
of the larynx is quite common, as each nerve traverses a long and un- 
interrupted course before it gives off the terminal twigs to the muscles 
of the larynx. The left recurrent is given off from the pneumogastric 
on a level with the transverse portion of the arch of the aorta around 
which it curves (Fig. 291) and passes upward in the groove between 
the trachea and the esophagus to the larynx. Aneurysm of the trans- 
verse portion of the arch of the aorta compresses it and causes degenera- 
tive changes and consequent laryngeal paralysis. Tumors of the 
mediastinum and of the neck or enlarged glands of the neck may com- 
press and injure it. The right recurrent nerve is given off from the right 
pneumogastric on a level with the right subclavian artery, around which 
it curves in close contact with the apex of the right lung. Aneurysm 
of the right subclavian causes compression and degeneration of the 
right recurrent laryngeal nerve, and paralysis results. Pleuritic inflamma- 
tion and adhesions at the apex of the lung may involve the right recurrent 
and cause laryngeal paralysis upon that side. ^Malignancy of the esopha- 
gus or other growth, or inflammatory swelling, may involve either the 
right or the left recurrent laryngeal nerve and produce unilateral paralysis. 

Symptoms. — The symptoms include hoarseness or even aphonia at 
the beginning of the paralysis. Later the unaffected cord compensates 
for the loss of motion on the affected side, and the aphonia or hoarseness 



LARYNGEAL PARALYSIS 495 

is improved. Dyspnea is absent. The laryngeal image shows the vocal 
cord on the affected side in the "cadaveric" position, i. e., half-way 
between adduction and abduction, while the unaffected cord performs 
both adduction and abduction without restraint. The epiglottis may 
deviate from the median line. 

Prognosis. — ^The prognosis depends upon the cause. If due to a 
transient inflammation or exudate, it is good under appropriate treat- 
ment. If due to syphilis, the prognosis is good if the case is properly 
treated. If due to some incurable disease, the prognosis is correspond- 
ingly grave. If dyspnea is present, the prognosis is more grave. 

Treatment. — When practicable, treat the disease causing the para- 
lysis as in postdiphtheritic or postexanthematic and syphilitic affections. 
If an incurable disease, as carcinoma or sarcoma of the mediastinum, the 
esophagus, or the larynx, is the cause of the paralysis, treat the distressing 
symptoms as they arise. If the thyroid gland is enlarged, give thyroid 
extract, or perform thyroidectomy if the extract fails. 

LARYNGEAL PARALYSIS FROM LESIONS OF THE MEDULLA AND 
THE NUCLEI OF THE SPINAL ACCESSORY NERVE. 

Laryngeal paralysis from disease or injury of the medulla oblongata 
and the nuclei of the accessory portion of the spinal accessory is character- 
ized by paralysis of all the intrinsic muscles of the larynx on the 
side involved, or, if only a few filaments are involved there will be 
paralysis of only one or at most two muscles of the larynx. It is still 
further characterized by the paralysis of certain muscles, extrinsic 
to the larynx, which are supplied by nerves having their origin in the 
immediate vicinity of the motor nucleus of the pneumogastric. Thus 
there may be paralysis of the facial, the acusticus, or of the nerves leading 
to the extremities. 

Pathology. — Laryngeal paralysis due to a central lesion is dependent 
upon the involvement of the spinal accessory roots, from which some of 
the fibers of the pneumogastric nerves arise in the floor of the fourth 
ventricle. There must be a lesion in the medullary or nerve roots supply- 
ing the larynx. Syphilis, locomotor ataxia, progressive bulbar paralysis, 
multiple sclerosis, and tumors of the neck and the brain comprise the 
chief morbid anatomy of central paralysis of the larynx. 

Diagnosis. — The diagnosis depends on the symptom complex of all 
the nerves involved. There is usually an associated paralysis of the 
nerves supplying the tongue, the palate, and the facial muscles, or of the 
nerves of audition, or of the extremities. Other regions supplied by the 
accessory root may be paralyzed. All the intrinsic muscles of the larynx 
may be paralyzed, or only a part of them, depending on whether all or 
only a few of the fibers from the motor pneumogastric nucleus are 
diseased. 

Prognosis. — I'lic prognosis is nearly always very grave, and even 
when the disease is due to syphilis it should be guarded, though under 
antisyphilitic treatment improvement may be expected. 



496 



DISEASES OF THE LARYXX 



Treatment. — The treatment should be varied to meet the symptomatic 
imHcations. If syphilis is present, the iodonncleoid*'or the iodide of 
potash should be given in large doses. If a malignant growth is at the 




Bilateral paralysis of the thyro-arytenoidei iiitenii and of the arytenoideus. 

bottom of the trouble, treat the unfavorable symptoms as they arise. If 
marked dyspnea is present from paralysis of the abductors on both sides, 
either intubation or tracheotomy should be performed. 



BILATERAL ABDUCTOR PARALYSIS. 

Etiology. — The causes of bilateral abductor paralysis of the vocal 
muscles are syphilis, mediastinal tumors, aneurysm, and enlarged medias- 
tinal lympjiatic glands. Neurasthenia is also a cause of the paralysis. 

Symptoms. — The symptoms have been so admirably given by N. L. 
Wilson in an article read before the American Laryngological, Rhino- 



/p^ 


m\ 




i^i 


^^^■r 



Position of the cords when emitting a high 



d tone and in abductor paralysis. 



logical, and Otological Society, in 1900, that I will quote him in this 
connection : 

"The patient gave a remote history of syphilis, and was somewhat 
addicted to alcohol; has had a few attacks of dyspnea, especially at night, 
for the past eight months. Voice only slightly husky, inspiration a little 



BILATERAL ABDUCTOR PARALYSIS 



497 



noisy, and expiration soundless. Occasionally had headaches. Oph- 
thalmoscope showed nothing abnormal. Heart and lungs normal, 
urine acid and clear, specific gravity 1020. There was no albumin or 
sugar. The laryngoscopic examination showed the epiglottis to be 
normal, mucous membrane of the larynx normal, the vocal cords white, 
with a small slit between them during inspiration. The left vocal band 
was immovable in the median line; the right moved slightly." (Fig. 293.) 
The patient was warned of the danger of sudden death from dyspnea, 
but refused to be tracheotomized. Three months later he died suddenly 
from dyspnea. 







Fig. 294. — Unilateral paralysis of the thyro-arytenoidei interiii and of the arytenoideus. . 
Fig. 29.5. — Paralysis of the thyro-aiytenoidei interni. 
Fig. 296. — Bilateral paralysis of the arytenoidei. 
Fig. 297. — Unilateral paralysis of the right arytenoideus. 

Fig. 298. — Paralysis of the adductor muscles of the larynx. It also shows the position of the 
rds in deep inspiration. 
Fig. 299. — Paralysis of the adductors and arytenoideus. 



Pathology. — When due to sypliilis the disease may affect the abductor 
muscles, the peripheral nerve filaments of the recurrent nerves, the nerve 
trunk, or the medulla. Wlien due to mediastinal tumors, aneurysm, or 
enlarged glands, the recurrent trunk is pressed upon, causing atrophy 
or other degenerative changes in the nerve fibers. When due to neuras- 
thenia, the flow of the nervous impulses througli the recurrent are 
inhibited. 
32 



498 ])isK.\si:s of tiuc laryxx 

Prognosis. — The paralvscs due to neurasthenia generally recover, 
though death may occur. When due to other causes, more than half die. 
When operated upon, more than two-thirds recover. In the syphilitic 
cases the administration of the iodides and mercury sometimes effects a 
cure. When due to mediastinal tumors, aneurysm, and enlarged glands, 
it may be necessary to remove a portion of the vocal cords pending 
the consideration of the operation or other treatment of the mediastinal 
disease. 

Treatment. — The faradic and galvanic currents have been used, and in 
but few cases with success. Antisyphilitic treatment has proved of 
value in a number of cases. Surgical treatment should be early recom- 
mended, as ])r()(rastination may lead to a fatal issue. 

Surgical Treatment. — Three methods of procedure are availaljle, namely, 
(a) tracheotomy, (b) intubation, and (c) laryngofissure and the removal 
of a part or all of the vocal bands. 

Tracheotomy is usually preferable, as it affords the least inconvenience 
to the patient and is ordinarily easily performed. The cyanosis, conges- 
tion, and edema of the tissues which sometimes complicates the case 
(A. G. Root) may, however, render this procedure difficult to perform. 
(See Tracheotomy.) 

Intubation may be performed for the temporary relief of the dyspnea. 
It is not suitable for permanent relief, as the tube may be coughed up, 
and its use is uncomfortable to the patient. 

Laryngofissure and the removal of a portion or all of the vocal cords 
may be practised if the tracheotomy tube is objected to. After this 
operation the vocal functions are sometimes gradually resumed. (See 
Laryngofissure.) 



CHAPTER XXVIII. 

THE SINGING VOICE. 

The range of the average voice is from two to two and one-half octaves, 
ahhough many singers embrace three to four octaves. 

The singing voice begins from the third to the sixth year, and changes 
but httle until puberty. At this time there is a decided change, especially 
in boys, in whom it becomes deeper or lower in pitch, assuming more 
the quality of an adult male. There is some change in girls' voices, 
although it is not so noticeable as in boys. The larynx becomes larger, 
the cartilages consolidated, and the cords longer and thicker. 

The vocal organs should not have special stress put on them during 
this transition period, as coordination is distributed by the rapid changes 
in the shape, the size, and the position of the parts of the larynx. 

Voice production is dependent upon three functions of the vocal 
apparatus. By "vocal apparatus," as used in this connection, is meant 
the larynx (primary source of tone), the chest (source of motive power), 
and the resonant chambers of the chest and the head. 

Without the motive power of the outgoing current of air through the 
larynx there could be no vibration of the cords, and without the vibration 
of the vocal cords and the outgoing current of air through the upper 
respiratory tract there could be no vibration or secondary tones or 
harmonics to enrich the laryngeal or primary tone. In other words, a 
voice, to be pleasing or "sympathetic," must have all the quahties which 
can be imparted to it by a proper respiratory act, a normal placement of 
the larynx, and unimpeded vibration of the vocal cords; also the richness or 
quality imparted to it by the resonance chambers of the chest and the 
head. 

Defects of the singing voice are, therefore, largely due to the following 
causes : 

(a) Improper methods of breathing. 

(b) Improper action of the extrinsic and the intrinsic muscles of the 
larynx. 

(c) Local disease of the larynx. 

(d) Faulty or imperfect use of the resonance chambers of the head 
and the chest. 

The nose is on(> of the most important resonant chambers, hence 
diseases or abnormalities in this region are especially productive of 
harm to the singing voice. The epipharynx, the soft palate, the uvula, 
and the tongue are also largely concerned in voice pro(hiction. Growths 
or diseased conditions of the epipharynx, the soft palate, and the tongue 
are therefore potent factors in defects of the singing voice. Enlarged 



500 DISEASES OF THE LARYNX 

tonsils, especially if they are adherent to the pillars of the fauces, mar 
the purity of the tone and interfere with its placement. The same is 
true of postnasal adenoids. In both instances the mobility and the 
normal action of the uvula form a curtain or valve which regulates the 
volume and the direction of the vibrating air current from the lar^Tix 
in its passage through the epipharynx and the nasal chambers. It is 
important that their action should be free and untrammelled. Postnasal 
adenoids push the soft palate forward and downward, while enlarged 
and adherent tonsils interfere with its free movement in an upward and 
backward direction toward the posterior wall of the pharynx. A voice 
thus modified loses its power to charm the ear. Not only is the quality or 
timbre imj)aired, but the range is also curtailed. I could cite instances 
in which the quality has been improved and the range increased one to 
three intervals by the removal of the tonsils. As adenoids are chiefly 
found in children, they do not so often affect the adult voice. On account 
of an associated postnasal catarrh with and subsequent to the atrophy 
of adenoids, the singing voice is often thereby indirectly affected. Post- 
nasal catarrh involves the postsuperior surface of the soft palate and 
produces a laxity of the tissues composing it, including the palatine 
nuiscles. There is an increase in the fibrous tissue, together with an 
edema (slight), and boggy condition of the muscular fibers. The uvula 
is relaxed and often hangs down until it touches the base of the tongue or 
the posterior wall of the pharynx. This gives rise to a tickling sensation, 
and is often a source of annoyance to singers and speakers. 

The presence of enlarged and diseased tonsils not only interferes with 
the muscular activity of the soft palate, but causes a chronic enlargement 
of the mucous membrane of the epipharynx and the oropharynx, thus 
augmenting the catarrhal condition already mentioned. A very common 
sym])tom of tonsillar disease is a sensation of a splinter of w^ood lodged 
in the throat. This is a symptom which, so far as I know, has not 
heretofore been attributed to this condition. I have often noted it, and 
regard it as significant of cryptic infection. 

Defects of the singing voice due to nasal diseases are chiefly due to 
an interference with the production of the harmonics or overtones 
which give quality and character to the voice. The bones of the 
face are so constructed that there are numerous cavities communicating 
with the nasal chambers. The lightness of the bones makes them 
admirable sounding boards for the primary tones of the vocal cords. It 
becomes apparent at once that any condition of the nose which interferes 
with the proper entrance of the column of air into the nasal and the 
accessory cavities will prevent the voice taking on the rich coloring or 
tonal qualities which make it pleasing to the human ear. 

Deflection of the septum, thickening of the nasal mucosa from chronic 
catarrhal inflammation, polypi, and other morbid processes interfere 
with the resonant chambers of the head. The mucosa of the nose is 
reflected through the normal openings into the accessory sinuses, and is 
here affected by catarrhal or other thickening simultaneously with the 
invasion of the nasal membrane. The openings into the sinuses are more 



THE SINGING VOICE 501 

or less closed by the thickening, and the resonant quality of the cavities 
is thereby diminished. More often the middle turbinal or a high devia- 
tion of the septum blocks the nose and affects the resonance of the 
voice. 

Jean de Reszke has well said that the more he studies the voice the more 
he is convinced it is a question of the nose. I have for many years been 
impressed that the chief charm in a public speaker's voice is its nasal 
quality. If this were lacking it failed to hold the attention of his auditors. 
I only speak of this to emphasize the fact that there is something very 
attractive to the average person in the resonance of nasal origin. There 
seems to be no other quality that can take its place. What is true in 
this regard of the speaking voice is doubly true of the singing voice. 

The mouth influences the singing voice to a marked degree, not only 
in modifying the resonance, but more particularly, in enunciation and 
articulation. The placement of the tongue, its concave-convex shape, with 
the tip elevated against the roof of the mouth, etc., modify the musical 
quality of the voice. Hence, all abnormal conditions of the tongue which 
interfere with its movements affect the voice. If it is "tongue-tied," 
adherent to the anterior faucial pillars, or the geniohyoglossus muscle is 
too short, the musical value of the voice is impaired. Hypertrophy of 
the tongue is occasionally an impediment to the acquirement of vocal 
excellence. 

The larynx being the primary source of tone, it is natural to presume 
that most defects of the singing voice are due to some lesion or faulty 
method of using it. This is probably true, although it should be re- 
membered that many of the laryngeal inflammations are indirectly the 
result of nasal disease. Chronic laryngitis and, in many instances, acute 
laryngitis are secondary effects of chronic nasal obstruction and catar- 
rhal sinuitis. Recurrent or persistent hoarseness should, therefore, lead 
to a thorough inspection of the nasal chambers for obstruction or 
sinus diseases. Hoarseness is not necessarily a sign of an antecedent 
nasal disease, as it is also a prominent symptom of laryngeal tubercu- 
losis, cancer, etc. 

Paplllomata or other laryngeal neoplasms interfere with the motility 
and the adjustment of the vocal cords, and thus produce hoarseness, 
aphonia, or spasm of the muscles of the larynx. Morbid growths in this 
region should be removed with great care and with due regard to the 
functional integrity of the vocal apparatus. Awkward or aggressive 
surgery might forever banish the possibility of a musical career, or 
even a voice for ordinary social purposes. 

Paresis of the Adductors from Aneurysm. — Gradual compression 
of citiier of the recurrent laryngeal nerves due to a developing aneurysm 
of the arch of the aorta may cause a partial paralysis one day, with 
characteristic choking spells, and on the following day all symptoms 
disappearing, only to recur again in a few days. Even though no other 
symptoms of aneurysm, such as dulness on percussion or bruit on aus- 
cultation, be present, the above symptom should be considered very 
suspicious. 



502 DFSEA.'^ES OF THE LARYXX 

(^tlier tumors or coiiditions that cause gradual com})ression of the 
recurrent larvnii;eal nerves may sliow the saiue symptoms. 

Methods of Breathing. Defects of the Singing Voice Due to Improper 
Methods of Breathing. — To obtain the purest and richest singing voice 
the method of breutiiing should he carefully cultivated. The natural 
method of breathing is not suitable for the singing voice (H. Curtis). 
It is adapted to the ordinary function of oxygenating the blood, but is 
poorly suited for singing. For this purpose the respiratory acts should 
be done in such a way as to give the most perfect control over the expira- 
tory current, and at the same time maintain the same Cjuality or color 
of the voice during the varying stages of the act. 

In order to obtain the most perfect control of the expiratory current of 
air for artistic purposes, the respiratory method should be such as will 
give the greatest chest capacity, as well as full control over the emission 
o^ the air for phonatory purposes. 

The quality or timbre is best maintained throughout all the registers 
by such a method as will keep the upper portion of the thorax in a fixed 
position. 

The control of the expiratory current for artistic purposes is a complex 
coordination of the muscles of the chest walls (scaleni and intercostals), 
the diaphragm, the abdominal walls, and the larynx. The singer 
should not, however, be made conscious of the part the larynx plays in 
this capacity, as this would lead to an undue tension of the laryngeal 
muscles. Nothing could be more damaging to the quality of the voice 
than this. In fact, the larynx has but an infinitesimal muscular function 
in voice production. The singer should be made to clearly understand 
that only when the laryngeal muscles are at "ease" can the voice 
charm the listener. The auditory nerve should only be conscious of 
quality, richness, sweetness, fulness, splendor, unlimited reserve, and all 
the emotions that make the inner self a free spirit, travelling through 
the world of ennobled thought and imagination. The most beautiful 
song, when coming from an overtense larynx, calls attention to the 
material, the singer, as opposed to the ethereal, the song, thus defeating 
the purposes of artistic singing. 

I have thus digressed at this point in order to emphasize the impor- 
tance, indeed the al)solute necessity, of maintaining a proper poise of the 
laryngeal muscles during the artistic activity of the expiratory current 
of air with which the singing voice is produced. 

The Inferior Costal Type. — The chest cavity is conical in shape, with 
the aj)ex at the top. It may be increased in all its diameters during the 
insj)iratory act by the action of the scaleni, the intercostals, and the 
diaphragmatic muscles. All these muscles should, therefore, be used to 
fill the lungs to their greatest capacity. The inferior intercostals and 
the diaphragm are especially important in this connection, hence it 
is usually s[)oken of as the inferior costal type. The upward and out- 
ward movement is chiefly confined to the ribs and the sternum below 
the sixth rib. The downward movement of the diaphragm pushes the 
abdominal viscera with it, and thus tends to increase the abdominal 



THE SINGING VOICE 503 

convexity. The experience of the great artists has shown that the lower 
portion of the abdominal walls should not be allowed to participate in 
this distention, as the perfect control of the expiratory current is thereby 
hindered. The lower portion of the abdominal wall should, therefore, 
be retracted, while the upper portion is allowed to distend. 

The upper chest wall should be maintained in the position it assumes 
during deep inspiration. That is, during expiration it should remain 
fixed in the position assumed during deep inspiration. In this way the 
resonance imparted to the voice by the thoracic cavity is increased and 
maintained of the same quality throughout all the registers of the voice. 
Failure to thus fix the upper chest wall will result in the voice taking 
varying tonal qualities as it passes from one register to another. I have 
heard singers whose voices were rich in quality in the middle register, 
but in passing into the upper or the lower register assumed an entirely 
difl^erent quality. This change is not always due to a failure to fix the 
upper chest wall as described, as it may also arise from improper place- 
ment of the soft palate. Nevertheless, it is important that the upper 
wall of the thorax should be maintained in the position assumed during 
deep inspiration. 

The inferior costal or artistic type of breathing may be analyzed as 
follows : 

(a) It is chiefly performed by the inferior portion of the chest walls and 
the diaphragm. 

(6) The upper abdominal walls also participate in the outward expan- 
sion. 

(c) The inferior abdominal walls are maintained in a retracted 
position during inspiration and expiration. 

id) The upper chest walls are maintained throughout inspiration 
and expiration in the position assumed during deep inspiration. 

The efi^ects sought for are : 

(e) The greatest chest capacity. 

(/) Perfect control of the expiratory air current. 

{g) A maintenance of the same resonant quality throughout all the 
registers. 

Factors which Influence the Voice. — Deviations from the foregoing 
type of breathing during the act of singing are detrimental to the artistic 
r[ualities of the voice. It is true that some of the greatest artists do not 
use this method of respiration. What their voices would have been 
had they used this method can only be conjectured. There are so many 
elements entering into the composition of a great artist, that a fault in 
one direction may l)e obscured or compensated for in other ways. For 
instance, an artist may use superior costal breathing and overcome 
in a large measure any voice defect resulting therefrom by the brilliancy 
of vocal execution or l)y the transcendent spiritual or mental conception 
which dominates the mind and the body during the singing. There is 
no shadow of doubt as to the transforming power of an exalted or over- 
mastering conception of the part being rendered. This alone does not 
make on(> a great artist. Th(> physifid inech;inisin whereby this con- 



504 DISEASES OF THE LARYNX 

ception is expressed should be so coordinated and adjusted as to not 
detract from its full expression. 

The Vocal Resonators. — The voice, like musical instruments, has its 
sounding' hoard. The sounding board of the piano and the violin are 
familiar to all. If the string of a violin were stretched upon a heavy slab 
of marble the tone given off would be weak and disagreeable. It would 
lack the overtones or harmonics which make it rich and grateful to the 
ear. The same string when adjusted on a violin gives forth a tone of 
great sweetness and })ower, as the sounding board adds numeious over- 
tones to the fundamental tone of the string. The fundamental tone 
predominates while the harmonics coordinate in such a Avay as to give it 
"color" or timbre. 

What is true of the violin string is also true of the vocal cords. The 
fundamental tone is weak and thin, but it is enriched by the harmonics 
of the resonance chambers of the chest and the head. 

The resonance chambers (soimding board) of the head are: (a) The 
ventricular pouches; (b) the pharynx; (c) the epipharynx; (d) the n ares; 
(e) the accessory nasal cavities; and (/) the mouth. 

The resonancefrom the chest has been referred to under Methods of 
Respiration. 

The ventricular pouches do not, perhaps, play an important role in 
the production of overtones. The pharynx (including the epipharynx) 
communicates with the mouth and the posterior nares. The soft palate 
acts as a valve or curtain which regulates the amount of the vibrating 
current of air going to the nose and the mouth. In this way the quality 
of the resonance is regulated to suit the musical expression of the singer. 
The soft palate is, therefore, an important part of the vocal apparatus. 
If it is elevated against the posterior wall of the pharynx, the voice 
assumes a peculiar and objectionable quality known as throatiness, a 
condition also assisted by the elevation of the posterior portion of the 
tongue (H. Curtis). 

The soft palate is prolonged downward in two pairs of folds known 
as the pillars (palatine arches) of the fauces. 

The anterior pillar contains the palatoglossus (glossopalatine) muscle, 
while the posterior })illar embraces the palatopharyngeus (pharyngo- 
palatine). They assist in the modulation of the voice by coordinating 
with the movements of the soft palate. The function of the uvula is 
not well understood. 

The faucial tonsils lie between the pillars, and when enlarged or dis- 
eased, affect their motility and impair the voice. They often become 
adherent to the sinus tonsillaris and thus very materially interfere with 
their action. I have no hesitancy in indorsing the opinions of Sir IMorrell 
Mackenzie, H. Curtis, and others who advocate their removal in adidts 
when they give rise to the slightest trouble. Curtis says their existence 
in the adult is unnecessary, as they serve no good purpose. When 
we remember that in childhood they are composed of lymphatic tissue, 
to meet the exigencies of the infectious fevers to which childhood is so 
susce})tiblo, and that in adulthood they are usually fibrous from repeated 



THE SINGING VOICE 505 

and long-continued inflammation or irritation, it is easy to understand 
why they no longer serve any useful purpose. 

If the pillars are adherent to the tonsils, they should be freed, and in 
most instances this should be followed by complete ablation of the 
tonsils. (See Operations of the Tonsils.) The immediate effect of their 
removal is sometimes detrimental to the voice. After a few weeks this 
passes away and the voice begins to show the value of the procedure. 
At first the loosened pillars may relax and fail to perform their muscular 
function. After a few weeks they become attached to the fibrous tissue 
formed in the sinus tonsillaris, and perform their function in a much 
better manner than before the tonsillectomy. Sir Morrell Mackenzie 
says he has never seen any other than beneficial effects to the voice 
follow their removal. 

The pharynx is supplied with numerous lymphatic masses, especially 
near its vault and along the lateral walls. The enlargement of the 
lymphatic tissue in the vault is commonly known as postnasal adenoids, 
while that along the lateral walls of the pharynx is called pharyngeus 
hypertrophica lateralis. When the scattered masses over the posterior 
wall of the pharynx are diseased and enlarged, the condition is known 
under various names as follicular pharyngitis, granular pharyngitis, or 
"clergymen's sore throat." 

Adenoids are not commonly present in adults, although they may be. 
Many children, however, have marked defects of the voice from their 
presence. The resonance is interfered with by the obstruction in the 
epipharyngeal space and the entrance to the nares. The soft palate is 
crowded forward and downward by them. The voice has a dead or so- 
called "nasal" quality, which in reality is an absence of nasal resonance. 
Jean de Reszke has said that the more he studies the voice, the more 
he is convinced that it is a question of the nose. In other words, the nasal 
chambers are the chief resonators of the voice. It is obvious, then, 
that adenoids are an absolute hindrance to the singing voice. The 
treatment is their complete removal (see Adenoids). 

Hypertrophica lateralis impairs the voice by perpetuating a chronic 
irritation and congestion of the parts, including the larynx. The voice 
becomes husky and the muscles of the larynx tire upon slight or moderate 
singing. The hypertrophic glandular masses should be removed. 

"Clergymen's sore throat," or chronic pharyngitis, is, according, to Sir 
Morrell Mackenzie, the most common cause of trouble to singers, the 
voice becoming husky and tiring upon slight use. Just behind the soft 
palate the muscles of the posterior pharyngeal wall contract in coordina- 
tion with those of the soft palate, and aid in closing or constricting tlie 
pharynx at this point. Resonance is, therefore, modified by the existence 
of inflammatory disease of the pharynx, as the muscles of the pharynx 
and the soft palate are edematous and somewhat restricted in their 
movements. 

Chronic pharyngitis is accompanied by a similar affection of the 
posterior wall of the soft palate and the uvula. A relaxed or elongated 
2ivnla is nearly always a sign of chronic o])i])haryngitis. The practice 



506 DISEASES OF THE LARYXX 

of ampiitatin<? the uvula under such circumstances should not be done 
without first attcniptino; to cure the preexisting pharyngitis. 

The tongue performs an important function in regulating the reson- 
ance chamber of the mouth. If there is a shortening of the geniohyo- 
glossus muscle, or an hypertrophy of the entire tongue, this function 
is impaired. I have frequently seen the tongue adherent quite high 
on the anterior pillars of the fauces. This not only interferes with the 
correct movements of the tongue, but with those of the anterior pillars also. 
In one case of this kind, where the tonsils had been completely removed 
!)y cautery dissection, hoarseness became a troublesome factor. 

Lingual tonsih and varicosities sometimes give rise to hoarseness and 
a web-like feeling in the larynx. 

"Tongue-tie" interferes with the proper performance of the glossal 
function, especially in articulation. 

The absence of some of the front teeth, or even marked irregularity of 
the same, might also interfere with resonance and articulation in singing. 

Cleft palate (either hard or soft) would for obvious reasons interfere 
with l)()tli resonance and articulation. 

The Nasal Chambers. — As these are the chief resonators or sounding 
boards of the voice, special attention should be directed to their condi- 
tion in searching for defects of the singing voice. This is of special 
importance in view of the fact that many pharyngeal and laryngeal 
affections are caused by preexisting disorders of the nose. 

The nose is divided into two cavities by the nasal septum, and these 
cavities are still further partially divided by the turbinated bodies. 
The lateral walls of the nares are in communication with numerous 
air cells or sinuses which communicate with the nasal chambers. 
Above the nose they open into the frontal sinuses, while posteriorly 
they open into the sphenoidal sinuses. Thus the bones of the face 
form numerous bony chambers which make up the chief sounding 
board of the vocal apparatus. At least it is this portion of the reson- 
ance apparatus that gives the voice its sympathetic and attractive 
quality. I would not minimize the importance of the chest and other 
resonance chambers, but I would emphasize the importance of the 
resonance chambers of the nose. 

Defects of the Singing Voice from Improper Methods of Respiration. — 
While there can be no well-defined analysis of the defects due to improper 
methods of breathing, there can, nevertheless, be a classification which 
will emphasize the underlying principles. The following is given for 
this purj)ose rather than to catalogue a series of defects: 

(a) Superior costal breathing does not use the entire thoracic capacity, 
hence the voice does not possess the reserve force and the evenly sus- 
tained quality afforded by the inferior costal type of breathing. 

(b) The same may be said of the abdominal type of breathing with 
even greater emphasis. The resonance is less pronounced than in either 
the su])erior or the inferior costal type, while the control of the expiratory 
breath is jerky. The voice is thereby rendered uneven and less sym- 
pathetic in quality. 



THE SINGING VOICE 507 

(c) On account of the greater difficulty in controlling the expiratory 
breath, the extrinsic and the intrinsic muscles of the larynx are put upon 
a tension in an involuntary attempt to compensate for the lessened control 
of the thoracic and the abdominal muscles. This at once impairs the 
artistic quahties of the voice and in some cases almost destroys its sing- 
ing qualities. The voice becomes rough, metallic, unsympathetic, and 
forced. The laryngeal muscles tire easily, prolonged singing being an 
impossibility. There is a feeling as of a web across the cords. Frequent 
ineffectual attempts are made to clear the throat. 

The foregoing symptoms may be present in so slight a degree as to 
escape notice, or they may be so pronounced as to ruin the voice. 

The superior costal or artistic type of breathing, if intelligently and 
faithfully practised, will avoid these difficulties and add materially to the 
power and attractive qualities of the singing voice. 

Defects of the Singing Voice Due to Tone Blindness. — J. Mount-Bleyer 
has called attention to a condition of the hearing centres of the brain 
which is neither a disease nor a defect, but is the result of inattention 
or lack of training. For instance, some hear an orchestra as a whole, 
while others distinguish the tone of each instrument; still others dis- 
tinguish the exact musical quality of each instrument. The difference 
is not so much in the mechanism of hearing as it is in the training which 
the brain centres have received. One, through a love of music, seeks 
for the finer qualities and variations, while another casually receives 
only the most general impressions from music. In the first place 
there is eager, expectant attention, while in the latter there is an 
indifferent, passive attention. It cannot be said that one has a good ear 
and the other a poor ear. Each may have equally good ears, or the one 
hearing the less may have the better. One, however, has a cultivated 
brain centre, which enables him to distinguish tones and qualities un- 
noticed by the other. Suitable training of mechanically perfect "ears 
which hear not," and "ears that hear and hear not," would rapidly 
convert them into highly discriminating organs of hearing. 

We often hear the remark, "I do not sing because I have no ear for 
music." In other words, he sings poorly because he has not edu- 
cated the so-called ear to fully appreciate musical intervals, rhythm, and 
the other qualities which make music so attractive. His belief is 
that his ears are defective as to musical matters, while the opposite 
may be true. The whole matter may be summed up in the statement 
that his "ears" have not been educated. 

J. Mount-Bleyer refers to Mr. Evans' work as superintendent of 
singing in the London schools, where he has 300,000 pupils under his 
direction. In no instance of obstinate inability to distinguisli one sound 
from another has he failed to educate them to appreciate sucli distinc- 
tions. This fact is significant and should encourage those interested in 
the cultivation of the voice to give more attention to the exact education 
of the "ear." 

Treatment. — I will here briefly outline the method of procedure used 
by ]M. Duclieniin, director of music in the asylums of Paris: 



oOS DISEASES OF THE LARYNX 

"M. Duchemin, setting aside all ideas of notations, commences by 
demonstrating to the pupil, by means of any musical instrument whatever, 
the interval of a note and that of a half-note. When the pupil has been 
sufficiently instructed in the distinction of these intervals, he makes him 
listen to the interval of a note and to that of a major third. He next 
makes him compare the major third with the fourth, and thus successively 
all the major intervals of the same octave. He then returns to the point 
from Avhich he started, and makes him compare the major with the minor 
intervals. When the pupil is acquainted with all the ascending intervals, 
he then repeats all the intervals, but in the descending scales. Finally, 
when the pupil has compared all the intervals by twos and twos, M. 
l^uchemin makes him listen to isolated intervals, either ascending or 
descending, at first to those comprised within a single octave, afterw-ard 
to those within two octaves, and so on." (]\Iount-Bleyer.) 

I have recently tried this method in a few cases where the claim was 
made that they "had no ear for music," with gratifying results. The 
quickness with which they learned to difi^erentiate between the various 
intervals was surprising to me. Both vocal and instrumental music, 
including the orchestra, assumed a new and delightful place in their 
lives. I would, therefore, urge that further attention be given to this 
part of the subject. 

It is not wnthin the province of this work to speak of methods of teach- 
ing, except in so far as they may apply to the defects of the singing voice. 
I cannot refrain, however, from the remark that, in my judgment ]M. 
Duchemin's method of procedure might be used with great advantage 
in both vocal and instrumental instruction as a preliminary training in 
musical education. Public schools, conservatories of music, and private 
teachers might, with great advantage to their students, follow this 
method. As music is made up of these intervals arranged in varying 
rhythm, periods, and sequence, it is of primary importance that the ear 
be trained to recognize them readily. This is all the more apparent 
when we remember that only when sensory impressions become intimate 
parts of one's experience, can they be reexpressed with power and beauty. 
An "ear" trained in this way will not only hear the music of others more 
accurately, but its possessor will be able to render music more accurately 
himself. 

I wish in this connection to consider a few of the more common condi- 
tions which impair the singing voice. 

Laryngitis of a subacute or chronic type is one of the most frequent 
derangements of the vocal apparatus to be found among singers. It 
renders the voice slightly rough or hoarse, and in extreme cases aphonic. 
The impairment is not constant, but comes and goes with the changes of 
the weather or with fatigue and use of the voice. Its tendency is to 
become more and more fixed with each recurrence. The etiology may 
be embraced in an antecedent nasal disease, an improper use of the 
laryngeal apparatus, or in some general condition which lowers the vital 
energy. If it is due to the first, the nose and the epipharynx should 
receive a])proj)riate attention, with a view to restoring their respiratory 



THE SINGING VOICE 509 

functions. Nasal obstruction, chronic sinuitis, etc., should be treated 
according to the descriptions given elsewhere in this work. The hoarse- 
ness may be due to an improper use of the vocal apparatus; the faulty 
method should be detected and corrected if possible. Six years ago a 
lady consulted me concerning her throat, stating that she was a student 
of vocal music, and that after moderate use of the voice she became 
slightly husky, there being the sensation of a web over the cords. Upon 
examination of the nose and throat I could detect no apparent cause for 
the condition. I found her, however, to be quite "high-strung," and 
asked her to go through some of her exercises in my presence. It was 
quite apparent that the whole muscular system, including the larynx, 
was on a "high tension." As she was a woman of culture and intelligence, 
I explained to her the necessity of overcoming this overtension, and 
offered her some suggestions as to how to do it. She was told to assume 
a natural and comfortable position in the chair, and to allow her arms, 
including the hands, to drop at her sides in extreme relaxation. She 
was then to allow the whole body, including the tongue and the lower 
jaw, to participate in the relaxation. Next she was to hum very softly 
the note that came naturally to her throat. After she had gone through 
with this exercise for a few minutes the vocal exercise was varied by 
singing the tones within a range of one-haK octave, cautioning her all 
the time to maintain extreme relaxation of the whole body. The exer- 
cises were gradually broadened to those she was in the habit of singing, 
the difference being in her physical condition during their production. In 
a surprisingly short time she thus trained the extrinsic and the intrinsic 
muscles of the larynx to a normal tension, which not only caused the 
hoarseness to disappear, but resulted in a placement of the larynx which 
gave added richness to her voice. There was a poise and dignity in it 
hitherto unnoticed. 

I do not mean to imply that all persons suffering from "high tension" 
can be made to sing beautifully, but I do want to say that many singers 
who become hoarse from overtension of the laryngeal muscles may be 
speedily and effectually relieved of the hoarseness and other tension 
anomalies of the voice by suitable advice and vocal exercises. The 
manner of going through with the exercises should be emphasized. 

If the hoarseness is due to some general systemic disturbance which 
results in laxity of the cords or the laryngeal mucosa, remedies suited to 
the case should be given. 



CHAPTER XXIX. 

DEFECTS OF SPEECH. 

Defects of speech are due to a great variety of causes, most of which 
are extra laryngeal. The larynx is the primary source of spoken tones, 
but it is not the complete vocal apparatus. It has been customary, in 
times past, to speak of it as the vocal organ, but this can no longer be 
done in strict conformity to well-known facts concerning voice produc- 
tion. While the vibrations of the vocal cords produce the primary tone, 
it is much modified by the chest, pharynx, epipharynx, nasal and 
accessory chambers, tongue, and the mouth. The character of the tone 
is also somewhat dependent u])on the respiratory movements of the chest, 
abdominal muscles, and diaphragm. The voice changes when there is 
a marked increase in the physiological activity of other parts of the body, 
as at puberty. This is especially noticeable in boys. INIental states 
exert a marked influence on the quality of the voice, as- may be noted in 
anger, joy, hatred, and love. 

It is, therefore, apparent that defects of speech may have their origin 
in parts remote from the laryngeal apparatus. The demands of domestic 
and social life often make it important that one possess a voice that is 
pleasing in timbre, range, pitch, and modulation, as well as in articulation. 
Ilence, attention should be directed to some of the more important lesions 
which impair the quality and integrity of speech. 

Speech and Brain Development.— That there is an intimate connec- 
tion between the develo])ment of the organs of speech and the cerebral 
centres of intelligence is, I think, scarcely open, to question. This is espe- 
cially true in children. I have seen them four years of age, apparently as 
bright and intelligent, with the exception of speech, as other children 
of the same age. They had reached the age at which spoken language 
should be used to communicate their wants and express their ideas. If 
it is not acquired within a reasonable length of time, they are in danger 
of becoming mentally inferior to other children of like age. That this 
inferiority is not altogether due to their inability to acquire knowledge 
through the senses, and through the natural inquisitiveness of childhood, 
has been shown by various writers who have reported remarkable 
increase in the mental development in children who were only trained 
to use the muscles of articulation, not yet having been led into the realm 
of thought, in which information concerning things and affairs is incul- 
cated. jNIakuen, of Philadelphia, reports cases in which the simple 
training of the muscles of the mouth, tongue, and fauces aroused the 
dormant faculties of the brain. The use of the motor tracts, of the 
muscles of speech, stinudated the centres of speech and thought, and 



DEFECTS OF SPEECH 511 

the patient passed rapidly from a "backward child" to one of ordinary 
intelligence. 

I will not at this time consider fully the interdependence of the organs 
of speech and mental development, but will only thus briefly refer to it 
in order to emphasize the importance of slight impediments of speech 
in children who are of the age at which language is most naturally 
acquired. It is obvious that an impediment at this time is a much more 
serious hindrance than it is after speech has been acquired. It is very 
much easier for him to cover up or compensate for a defect in the organs 
of speech, if the faculty of speech has been already acquired, than it is 
if that faculty is not developed. Hence, abnormalities of the organs of 
speech, which develop after speech has been acquired, result in but 
slight defects of speech; whereas abnormalities of a similar nature, in a 
child who has not yet acquired the faculty of speech, will in some cases 
prevent the acquisition of spoken language, while in others it will only 
interfere with it to such an extent as to make it defective. If this were the 
extent of the damage done, it might be passed over with comparative in- 
difference; but, as I have already suggested, mental development is also 
hindered. I have no doubt that a considerable number of the so-called 
"backward children" coming under this category are so chiefly on 
account of a slight physical imperfection of some part of the organs of 
speech. I do not mean to say that all "backward children" come under 
this classification, as no doubt many of them are defective in cerebral 
development from quite different causes. I only wish to call attention 
to the fact that each case should be carefully studied, the physical 
impediments to spoken language corrected, and suitable training of 
the organs of speech instituted, in order to give the child the best possible 
chance of taking the position in society to which he was born. 

An analysis of the peripheral causes of the defects of speech is inter- 
esting as well as instructive, especially to those who meet them in practice, 
or at least to those who attempt to treat them. Defects of speech are 
subdivided into six varieties, by R. Cohen, of Vienna as follows : 

1. Stammering. 

2. Stuttering. 

3. Nasal twang. 

4. Defects due to malformations of the hard and soft palates. 

5. Deaf-mutism. 

6. Defects of speech due to diseases of the central nervous system. 
Instead of following the classification given by Cohen, the author will 

treat the subject under the following heads: 

1. Defects of speech of nasal origin. 

2. Defects of speech of epipharyngeal and faucial origin. 
''). Defects of speech of lingual origin, 

4. Defects of speech of laryngeal origin. 

5. Defects of speech of thoracic and abdominal origin. 
(). Defects of speech due to deaf -mutism. 

7. Defects of speech due to malformations of the palate. 

8. Defects of speech of central origin. 



512 DISEASES OF THE LARYXX 

1. Etiology of Defects of Speech of Nasal Origin.— (a) Deflection 
of the septum, (b) Spurs or ridges on the septum, (c) Split or 
double convexity of the septum from an old traumatic lesion or abscess. 
{d) Nasal polypi or other neoplasms, (e) Chronic turgescence of the 
inferior nasal conchae. (/) II}q^crtrophy of the inferior nasal conchse. 
(</) Hypertrophy (mulberry) of the posterior ends of the inferior and 
middle conchte. {h) Congenital occlusion of the posterior nares. {i) 
Displacement of the columnar cartilage. (j) Enlargement of the 
middle conchse from hyperplasia or cystic degeneration, (k) Obstruc- 
tion to the olfactory fissure. 

The foregoing conditions do not cause pronounced defects of speech, 
as they only interfere with the resonant quality of the voice. Nor 
tlo they materially interfere with the muscular mechanism taking part 
in speech production. 

In a general way they may be said to produce those changes in the 
voice which make it "dead," "muffled," "thick," "flat," or lacking in 
resonance. The speech is still further modified by the diffidence so 
often accompanying nasal obstruction. The diffidence, backwardness, 
or timidity is due to a self-consciousness, to which the defect gives rise, 
and to a direct effect upon the brain and general system, through the 
lymphatic and venous stasis attending nasal and postnasal obstruction. 
Guye, of Amsterdam, has called attention to a condition which he calls 
"aprosexia," or difficult attention. 

Inability to fix the attention is often attended by diffidence and timidity, 
and not only is articulation impaired thereby, but fluency and coherency 
is also somewhat affected. 

The elementary sounds of spoken language which depend largely 
on the resonance of the nasal chambers are not so markedly impaired 
as those but slighdy depending upon it. For instance, the letters m, n, b, 
and (/ derive their peculiarity from the initial sound, while the final vowel 
and nasal tones are secondary. Notwithstanding the fact that they are 
secondary, their absence or suppression makes a noticeable change in the 
speech, and amounts to a defect. If the final vowel-nasal sound in the 
above examples were more prominent, the nasal obstruction would not 
interfere with speech nearly so much, as the speaker could "force" them, 
and thereby somewhat overcome the apparent effects of the stenosis. 
The letters m and 71 end in a kind of "hum" which is very difficult to 
produce in nasal obstruction, especially when the hum is somewhat 
suppressed. 

The letters h and d seem to begin with the sound thrown forward 
against the lips (6) and against the tip of the tongue and roof of the 
mouth (d) respectively. The initial sound is, however, made in the 
larynx and rendered resonant in the chest and nasal chambers. Nasal 
obstruction modifies the resonance, thus causing a "dead" or "flat" 
tone to exj)lode at the lips or the tip of the tongue. Thus the speech is 
rendered defective. We might continue the analysis of the various 
sounds in speech, siiowing how nasal obstruction from one or more of 
the foregoing conditions aft'ects the beauty, music, rhythm, and coherency 



DEFECTS OF SPEECH 513 

of speech. We might go still farther and show that coherency of thought 
is impaired also. 

2. Etiology of Defects of Speech of Epipharyngeal and Faucial 
Origin. — (a) Postnasal adenoids. (6) Fibroma or other neoplasms 
of the nasopharynx (epipharynx) . (c) Chronic catarrhal thickening 
of the mucosa of the epipharynx. (d) Hypertrophied or hyperplastic 
faucial tonsils, (e) Adhesions of the anterior and posterior pillars of 
the fauces to the tonsils. (J) Depression of the soft palate against the 
root of the tongue by the postnasal adenoids, (g) Paralysis of the 
palatine muscles, especially those of the membranous curtain which 
control the current of air passing to the nares. (h) Paralysis of the soft 
palate and uvula, (i) Adhesion of the anterior faucial pillars to the base 
of the tongue, (j) Cleft soft palate and uvula, (k) A shortened soft 
palate, as is sometimes found after operation for cleft palate. 

In the above table the muscular mechanism of speech is affected, and 
the speech defects are correspondingly more pronounced. The explana- 
tion of the more marked speech defects which seem to have their origin 
in this classification is not as easy as may appear on first thought. We 
cannot say that the speech is defective because the muscular action of the 
parts is interfered with, because many cases come under our observa- 
tion with great muscular impairment who have little impediment of 
speech, while others can scarcely be said to have articulate speech at all; 
and in still others they cannot be said to have coherent thought. The 
explanation in some cases is embraced in the fact that the muscular 
impairment existed quite early — before articulate speech was acquired. 
The impediment thus interfered with the acquirement of articulate 
speech. The presence of postnasal growths produced mental hebetude, 
(aprosexia), heretofore referred to, and the mental ability to acquire 
articulate speech and consecutive thought was thus impaired. In a few 
years the growing child becomes more vigorous in mind and body, and 
makes renewed and voluntary efforts at articulate speech. His failures 
humiliate and irritate him. He avoids the necessity of speech as much 
as possible. The speech centres and motor vocal tracts are little used, 
and lie dormant. His mental growth is thereby retarded. The sensitive, 
reticent child loses the mental growth to be gained by spoken language. 
He becomes and is regarded as a "backward child." 

It becomes the duty and privilege of the rhinologist and laryngologist 
to loosen the bonds which fetter his imprisoned mind, thus enabling him 
to enjoy the common pleasures of life, even though he may never become 
a brilliant member of society. 

3. Etiology of Defects of Speech of Lingual Origin. — (a) Inflamma- 
tory adiiesions binding the tongue to the anterior faucial pillars and 
epiglottis. (b) A congenital shortness of the geniohyoglossus muscle. 
(c) Tongue-tie. (d) Enlargement of the tongue, (e) Excessive enlarge- 
ment of the lingual tonsils. 

Of the foregoing, the most imjK^rtant arc adhesions of the tongue to 
the anterior faucial pillars, tongue-tie, and shortening of the genio- 
hyoglossus muscle. Either condition materially interferes with the 



514 DISEASES OF THE LARYXX 

articiilatorv function of the tonc;ne, thus impairing speech. Lisping 
is a common sign in these conthtions. If these lesions exist prior to the 
acquirement of speech, they may give rise to the chnical picture hereto- 
fore referred to under "backward clnlch-en." The early correction of 
these physical imperfections may place the child on an equal footing with 
his fellows, and save society the disagreeable presence of a crippled mind 
in its midst. 

4. Etiology of Defects of Speech of Laryngeal Origin.— (a) Too 
great strength in the uplifting muscles of the larynx, [b) A weakness of 
the (lown-])ulling muscles of the larynx, (c) Laryngitis, [d) Singer's 
nodules, [e) Chorditis nodosum. (/) Tuberculous inflammation and 
infiltration, (r/) Perichondritis. (A) Laryngeal rheumatism. (?') Catar- 
rhal accumulations, (j) Neoplasms, (k) Paralysis of the intrinsic 
laryngeal muscles. 

If the acute affections of the larynx, as laryngitis, and the chronic 
conditions, such as chronic laryngitis, laryngeal tuberculosis, peri- 
chondritis, paralysis, rheumatism, and neoplasms which cause hoarseness 
or aj)honia, are omitted, there is little to catalogue as causes of defects of 
speech. This is the more surprising when we recall the fact that the 
larynx is the primary source of the voice. 

^lakuen has referred to a condition of the extrinsic muscles of the 
larynx Avhich rendered the voice sibilant and falsetto. It is given in the 
table above in a and b, and is interesting because it illustrates one of 
the fundamental problems in voice culture — namely, voice placement. 
If the larynx is allowed to rise too high the voice becomes falsetto and 
unnatural in cjuality. If, on the other hand, the laryngeal box is held 
down in its proper position, the voice assumes its natural register, the 
tone being pure and pleasing to the ear — that is, it is natural. 

The natural and simple things of life appeal most strongly to normal 
minds. The simple rural scenery, the grandeur of the mountains, the 
simple melodies of the negroes, the rugged vitality of the Wagnerian 
opera, and the eloquence of the orator stir the imagination, quicken 
and fascinate the mind, as the unnatural, the complex, and the artificial 
cannot do. 

Hence the aim should be to give those having defective speech a 
speech that is simple and natural. It should be natural in quality, tone, 
pitch, ti)nJ>rr, and rhythm, as well as in modulation and articulation. 

."). Etiology of befects of Speech of Thoracic and Abdominal 
Origin. —((■/) Pulmonary tuberculosis in its relation to stammering. 
(b) Irregularity of the respiratory rhythm. 

Irregularity of the respiratory movements is an almost constant 
factor in stammerers. AVhether this is due to some fault of the respiratory 
centre, or to some peripheral lesion, has not yet been determined. 
Makuen has called attention to the fact that all, or nearly all, stammerers 
are either tuberculous, or come from families with this disease well 
marked in its history. He thinks the peripheral tuberculous lesion 
accounts for the irregularity of the respiratory rhythm, which in turn 
causes the stammering. 



DEFECTS OF SPEECH 515 

His conclusion is not necessarily correct, as the lack of rhythm may 
be due to developmental causes within the medulla, or along the motor 
nerve tracts leading to the diaphragm, lungs, and intercostal muscles. 
It is a well-recognized fact that those having a tuberculous tendency, 
especially those inheriting it, have a lowered cellular vitality, and that 
nutrition, or the processes of metabolism, are imperfectly performed. It 
is therefore possible to explain the lack of respiratory rhythm as being 
the result of the malnutrition and faulty development of the respiratory 
centre and the motor respiratory tracts. 

Whatever the explanation may be, the clinical fact remains, that 
nearly all persons who stammer are of tuberculous parentage and complain 
of ill health. Another fact, however, which makes it seem probable that 
the lesion is peripheral (in the lungs and diaphragm) is that under 
suitable treatment and training they may be freed from the speech 
defect. 

La Fayette Page calls attention to intoxications arising from diseased 
conditions of the upper respiratory tract. He cites the work of Schwalbe 
and Retzius, who demonstrated the connection of the lymphatic vessels 
of the nasal mucous membrane and those of the cranial cavity. Through 
the lymphatic and venous stasis of the nasal mucous membrane, the 
effects extend to the cranial cavity, thus giving rise to mental dulness. 

He also cites the intimate nervous connections between the nasal 
mucous membrane and the cortical centres of the brain, as a possible 
source of mental dulness and irritability. 

Makuen in his writings seems to lay greatest stress on impairment of 
the organs of speech, as the larynx, fauces, nose, or tongue, as the chief 
hindrances of mental growth and development. 

In the opinion of the author, defects of speech and mental acumen are 
due to complex conditions which it would be difficult to define. It appears, 
nevertheless, that children who are defective in speech are improved 
by correcting, either surgically or by training, the physical impediments 
to speech. We also know, from clinical observation, that upon the 
removal of postnasal adenoids or section of the geniohyoglossus muscle, 
etc., the mechanism of speech and the mental activity of the child are 
often much improved. Those who hold, as Guye and Page, that the 
mental quickening is due to the removal of the cause of the venous and 
lymphatic stasis, overlook the fact that the mechanism of speech is at the 
same time improved. The soft palate which was crowded down against 
the base of the tongue is freed, or the tongue is loosened, and resumes 
its normal function in articulate speech. Again, those who hold the views 
of Makuen to the exclusion of all others overlook the fact that the veno- 
lymphatic stasis, with its attendant toxemia and brain hebetude and 
irritability, is overcome and allows the brain to resume its normal 
activity. 

It should not be forgott(Mi tliat the toxemia referred to by Page affects 
the system much deeper tiian the brain. The whole system is poisoned, 
as has been shown })y the author in various articles on moutli breathing. 

There may be great imjKTfcction of speech without iiii])nirmcnt of 



516 DISEASES OF THE LARYNX 

the mental faculties. Nevertheless, it must be said that in nearly all 
cases "the speech belieth the man." 

Elegance of speech is an index of a finished mind. Training the 
organs of speech improves not only the expression of thought, but 
the thought itself is more elevated, more finished. The quality of mind 
is improved l)y a better mode of expression. 

6. Defects of Speech Due to Deaf-mutism. — This subject is quite 
fully considered under deat'-mntism, and will only be briefly analyzed in 
this connection. 

(a) Congenital defect of the auditory apparatus. 
{b) Acquired defect of the auditory apparatus. 

(c) Nasal and epipharyngeal diseases. 

(d) Improper and untimely training. 

(e) No training. 

Congenital defects of the auditory apparatus are probably present in 
about one-half of the cases of deaf-mutism, whereas in the balance the 
defect is due to the ravages of some disease, usually one of the exan- 
thematous fevers. In either instance the child is partially or totally deaf, 
and cannot, therefore, readily acquire the faculty of speech. He is not 
mute because the organs of speech are defective, nor because the centres 
of speech are impaired. Both the peripheral organs of speech, and the 
central mechanism of the brain may be in perfect condition. The 
child is mute because he cannot hear others speak, and is thereby de- 
prived of the most useful aid in learning, namely, imitation. If he learns 
to speak he must be taught by other and more difficult methods. He 
must be given timely and proper special training. If he has acquired 
deaf-mutism after having some ability to speak, he may not be a mute 
in the full sense of the word, but may need some special training to 
prevent his losing the little speech he already possesses. If the 
deafness comes before the seventh year of age, there is a strong tendency 
to lose the faculty of speech; hence, special training is necessary to 
maintain that already acquired, as well as to broaden it. If the deafness 
comes on after the seventh year, the patient rarely loses the faculty of 
speech, hence his training can be more simple than that of a child losing 
his hearing before that age. 

Reference has been made under Deaf-mutism to the interdependence 
of the brain development and the use of the organs of speech. Brain 
development and intellectual growth depend largely upon the voluntary 
use of the organs of speech. It is a common observation with most of us 
that an idea or train of thought is much clearer after having been ex- 
pressed in words. The growth of the brain seems to depend upon the 
cooperation of the various senses and peripheral organs. The intelli- 
gence of the child will, therefore, largely depend upon the use of its vocal 
apparatus, as well as all the other peripheral organs of the body. 

At certain ages the various faculties of the brain develop most 
naturally, and these periods should be taken advantage of by his instruc- 
tors. At one time the imagination, which later in life finds expression 
in so many practical ways, has the ascendancy. The training at this 



t 



DEFECTS OF SPEECH 517 

period should be of such a character as to lead the imagmation along 
wholesome lines. It should be bridled, but not suppressed. When 
adulthood is reached, and the practical affairs of life must be faced, the 
faculty once known as imagination is utilized in foreseeing the outcome 
of a given series of events. Cause and effect, and the sequence of events, 
will be correctly interpreted, somewhat in proportion to the character of 
the training received during the imaginative period in childhood. 

The other faculties of the mind should also receive due consideration 
in the training of the child. The child that is deaf needs this training 
tenfold more than the one with normal hearing. It becomes obvious, 
therefore, that the deaf-mute needs a teacher well schooled in the knowl- 
edge of the child mind, that he may facilitate its unfolding in the most 
wholesome and natural manner. Not one mother in ten thousand is 
fitted for this task, and even if she were, her love for the child would 
probably make her its worst enemy, in so far as its proper training and 
restraint are concerned. The proper thing to do, therefore, is to place 
the child who is a deaf-mute under the care of the most competent 
teacher available for the purpose, at the earliest possible time, certainly 
before the sixth year of age. 

The child that has no training will remain a deaf-mute. He may 
go through the manual sign language, learn to communicate with his 
fellows, but he will always be much handicapped in the race of life, as 
his communication with his fellows must be limited to the few who have 
likewise learned the sign language. Then, too, he is forever debarred 
from the pleasure and developmental power derived from the mechanical 
action of the vocal apparatus, and the pleasurable sensation experienced 
in ventilating the blood and stimulating articulation, which accompany 
voice production (Makuen). 



CHAPTER XXX. 

NEOPLASMS OF THE LARYNX. 

Benign tumors of the larynx and the trachea are characterized by 
absence of pain and the absence of a tendency to recur, or to destructive 
processes. Mahgnant neoplasms, on the contrary, are characterized 
by pain, recurrence, and destructive processes. 

Varieties. — ^Almost all t}^es of benign tumors occurring elsewhere 
in the body are found in the larynx. The following are more or less 
frequently reported in the literature: Papilloma, fibroma, myxo- 
fibroma, polyp, cystoma, lipoma, telangiectases, chorditis nodosa, and 
pachydermia laryngis. 

Location. — In looking over the literature for a period of ten years, I 
foinid lipoma and cystoma on the epiglottis; cystoma on the ventricular 
pouches; lipoma, cystoma, and papilloma in the arytenoid region; polyp, 
telangiectasis, fibromyxoma, papilloma, fibroma, singer's nodules 
(chorditis nodosa), and myxocystoma on the upper surface of the vocal 
cords and in the subglottic region. These and doubtless other benign 
neoplasms occur in the locations indicated. 

Etiology. — Much has been written, while but little is known, concern- 
ing the exciting causes of these growths in the larynx. 

Jonathan Wright says: "There is a strong likelihood that if these 
tumors are not the result of chronic inflammatory changes, the chronic 
imflammations play an important role in their etiology, and that this 
should be borne in mind in the treatment." They occur at all ages, but 
most frequently in middle adult life. Papilloma, however, occurs more 
frequently in children, measles seeming to be a prolific exciting cause. 
Both men and women are affected, but they are found more frequently in 
men. Sir Felix Semon has called attention to the fact that they are 
described in Germany and France more frequently than in the United 
States or England. 

Benign neoplasms are relatively more common among street vendors, 
singers, and speakers. Congenital tumors are rare. Papilloma is 
the most common variety. The anterior commissure is the most fre- 
quent site for laryngeal tumors. Lipoma rarely occurs within the cavity 
of the larynx, but is located extrinsically on the anterior surface of the 
epiglottis. Syphilis and tuberculosis, though they produce growths of 
their own kind, have little influence in causing iimocent neoplasms. 
Papilloma, fibroma, and singer's nodules are more frequent than lipoma, 
myxoma, and cysts, (jerhardt says he has never seen an adenoma, 
a chondroma, angioma, or a neuroma. Others, however, have reported 



NEOPLASMS OF THE LARYNX 519 

adenoma in the larynx. Moritz Schmidt, in his work on New Growths 
of the Upper Air Passages, gives the following table of laryngeal tumors 
seen in his clinic of 32,997 cases in ten years : 

Men. Women. Cases. 

Fibroma 178 78 256 

Papilloma 31 15 46 

Singer's nodules 56 53 109 

Lipoma 1 1 

Myxoma 3 3 

Fibromyxoma 1 1 

Tuberculous tumors . . 14 22 36 

Cysts 2 6 8 

Sarcoma 3 3 

Carcinoma 61 15 76 

Tracheal carcinoma 1 1 2 

This table is significant, and is contrary in some respects to the accepted 
opinion. For instance, in the above table fibroma occurs more frequently 
than papilloma. He found 256 fibromata and only 46 papillomata. 
Singer's nodules occurred in 109 cases, hence both the fibromata and 
the singer's nodules (chorditis nodosa) were found more frequently than 
papillomata. The apparent discrepancy is, no doubt, in the differential 
diagnosis, which is often carelessly made. I' is too often made without 
a microscopic examination, and is, therefore, often incorrect. 

The discussion concerning the exciting causes of benign neoplasms 
may be summarized as follows: 

The causes are (a) local and (6) constitutional. 

(a) Prominent among local causes is irritation. This pi-oduces 
hyperemia and cell activity, hence the persistence and the exaggeration 
of these two conditions may endanger life by allowing the tumor to grow 
so large as to interfere with respiration, or they may assume malignant 
tendencies. Mouth breathing is an important factor in producing irrita- 
tion of the larynx. The required amount of moisture and warmth is 
not carried to the larynx, and the mucous membrane is overtaxed by 
the burden thrown upon it. The imperfectly prepared air causes a 
dryness as well as a hyperemia incident to the increased physiological 
activity of the mucosa, and the resultant irritation leads to an increased 
cellular activity. In the "hurry," so to speak, the cellular arrangement 
is disarranged and neoplastic growths result. 

(b) Constitutional influences play an insignificant part in the etiology 
of innocent neoplasms. This does not take into consideration the 
specific constitutional dyscrasias, as syphilis and tuberculosis, which 
produce peculiar local laryngeal redundancies. 

In an adult laryngeal papilloma is often associated with a warty skin, 
so much so that we can almost speak of a "warty diathesis." This 
theory was advanced by Fauvel, but it may be said, on the contrary, 
that the skin and the larynx have a totally different developmental origin. 
Sir Morrell Mackenzie maintained that syphilis and tuberculosis exer- 
cised a decidedly antagonistic influence to the development of new forma- 
tions. Lennox Browne did not share this view, his experience rather 
proving the reverse. Moritz Schmidt thinks they favor new formations, 



520 DISEASES OF THE LARYNX 

because they always induce a low state of resistance or a local vulner- 
ability. 

The Tendency to Malignancy. — It has been held that operative inter- 
ference has a tendency to convert benign growths into malignant ones. 

This belief grew out of the fact that cases operated upon and thought 
to be benign were shown to be malignant in the recurrent state. Sir 
Felix Semon has shown that unoperated cases show even a greater per- 
centage of converted malignancy than the operated ones. The following 
are his figures: 

In a total of 10,747 benign cases reported in the literature, 45 after- 
ward became malignant. They were divided as follows: 

In 821G operated cases, 33, or 1 in 249, became malignant. 

In 2531 non-operated cases, 12, or 1 in 211, became malignant. 

It is thus shown that a greater percentage of the non-operated cases 
become malignant. These figures go a long way toward disproving the 
old notion that operative interference is an active factor in converting 
non-malignant neoplasms into the malignant variety. At the same time 
we must reckon the immense benefits derived by operations upon cases 
which do not become malignant, but continue to be troubled by the benign 
neoplasms. 

Neoplasms of the Subglottic Space.— Ferreri states, with reason, 
that subglottic polypi often cause greater obstruction to respiration 
than polypi of the supraglottic space. They do not, however, cause a 
change in the voice until they come in contact with the vocal cords, 
whereas, tumors of the supraglottic region cause it from the beginning. 

The development of subglottic polypi is insidious, hence they are not 
usually diagnosticated until well advanced, a fact which explains why 
they are usually larger than supraglottic polypi. 

The most common form of benign subglottic tumor is the fibroma. 
Myxoma does not occur quite so frequently, but it is not uncommon to 
find it associated with fibroma in the form of a myxofibroma. Ferreri 
also says that, exceptionally, cysts, chondromata, and circumscribed 
keratosis have been observed in the subglottic space. Papilloma is rarely 
found in the subglottic region. When present they are difficult to remove 
by the intralaryngeal route, except by direct laryngoscopy. Thyrotomy 
(laryngofissure) may therefore become necessary, or infrathyroid 
laryngotomy may be the chosen method of operation. 

The endolaryngeal methods of operating are with forceps, the snare, or 
the galvanocautery, either by direct or indirect laryngoscopy. Attacks 
of suffocation may render tracheotomy imperative, in which case the 
growth may be rcMnoved through the tracheal wound. 

Papilloma. — Etiology. — According to Jonathan Wright, this type of 
neoplasm occurs more frequently in the larynx than any other 
variety. According to the table of Moritz Schmidt fibroma occurs 
more frequently. They are closely related to various inflammatory 
growths which accompany syphilis, tuberculosis, and pachydermia. 
In view of this fact, many laryngologists regard chronic inflammation 
as an etiological factor. As already stated in General Etiology, 



OPERATION BY INDIRECT LARYNGOSCOPY 521 

this is still a mooted question. According to Jonathan Wright, they 
are usually classified as papillary fibromata. This may account in 
part for the discrepancy between Schmidt and other writers. Schmidt 
may have classified as fibromata what others call papillary fibromata. 
Schmidt observed papilloma in about 9 per cent, of his cases, Schr5tter 
in about 18 per cent., and Moure in about 50 per cent. Schmitzler and 
Killian say they occur more frequently in children, and that fibromata 
occur more frequently in adults. 

Symptoms. — Papilloma ta are usually attached to the anterior third 
of vocal cords, or at the anterior commissure, though they may spring 
from any portion of the larynx. They may be difi^use, sessile, or peduncu- 
lated. If pedunculated, the attachment may be below the cords, while 
the tumor is above them, or vice versa. They may be congenital, in 
which event the child is often aphonic from birth. Hoarseness with 
increasing aphonia is suggestive of papilloma. In children the tumor 
can easily be felt by digital examination when it is above the cords. They 
vary in size from a grass seed to a hickorynut. They occur both as 
single and multiple tumors. When removed they often recur, though not 
necessarily at the old site. 

Microscopically they have a stratified epithelial covering over a core of 
more or less vascular connective tissue. The outward growth of the 
epithelium is in contrast to the involuted growth of carcinoma. True 
nests or pearls of epithelial tissue have been found. 

Treatment. — The treatment ranges anywhere from non-interference 
to tracheotomy or laryngofissure. Spontaneous cures have been reported. 

The growths may sometimes be removed by indirect laryngoscopy 
with laryngeal forceps after anesthesia with a 10 to 20 per cent, solution 
of cocaine. The removal by direct laryngoscopy is a much better 
procedure. 

OPERATION BY INDIRECT LARYNGOSCOPY. 

In describing this operation for the removal of papilloma, it must be 
taken as a type of surgical procedure used in the removal of nearly all 
varieties of benign laryngeal neoplasms. Each case will, of course, 
require some modification of the various steps in the operation. 

Technique. — The Preparation of the Patient. — (a) The throat should 
be gently sprayed with Seller's or Dobel's solution. The fauces and the 
larynx should then be sprayed with a 2 per cent, solution of cocaine to 
reduce the reflex irritability. 

(6) The larynx is then swabbed with a 10 per cent, solution of cocaine. 
This should be repeated at intervals of five minutes until anesthesia is 
induced. If this does not produce anesthesia after several applications, 
one or two applications of a 20 per cent solution should be made. This 
strength of solution should be used sparingly and with caution, although 
in my experience the larynx has been quite tolerant of cocaine. 

(c) The laryngoscopic mirror is introduced into the oropharynx with 
its reflecting surface directed downward and forward so as to reflect the 



522 DISEASES OF THE LARYXX 

rays of light from the head mirror to the growth, the tongue being gently 
rolled forward on the forefinger of the left hand. The epiglottis is 
thereby lifted, exposing the larynx to view. 




Krause-Heryng laryngeal forceps. 

(d) Next introduce the curved 
laryngeal pincette or double cutting 
forceps (Fig. 300) into the upper 
space of the larynx until its cutting 
extremity touches the growth (Fig. 
301) . It must be borne in mind that 
the image in the mirror is reversed, 
hence the movements of the instrument 
should be directed in an exactly oppo- 
site direction from what appears to 
be necessary according to the image in 
the mirror. For instance, if the tip 
of the instrument seems to need a 
more forward position, so manipulate 
the handle as to move the tip back- 
ward, i. e., lower the handle. If the tip 
of the instrument seems to be too near 
the posterior portion of the image, it 
is in reality too near the anterior por- 
tion. A little practice upon a model 
or upon a patient, will familiarize the 
student with this procedure. The 
surgeon soon learns to intuitively 
move the instrument in the proper 
direction. 

It is of great aid to first firmly fix 

in the mind the anatomical relations 

of the various parts of the larynx. For 

exam])le, that the epiglottis stands at the anterior commisure of the 

larynx, and the arytenoid ])ronn*nences at the posterior commissure. 




Detailed drawing showing the laryngea 
forceps placed to remove the neoplasm. 



MALIGNANT NEOPLASMS OF THE LARYNX 523 

These simple anatomical guides, if impressed upon the memory of the 
operator, will, all unconsciously, lead him to intuitively guide the laryn- 
geal instrument in the proper direction. 

(e) Having located the growth with the laryngeal forceps or pincette, 
so manipulate the handle of the instrument as to separate the tips, and 
then with a slight downward movement of the instrument close the 
forceps upon the neoplasm and remove it, en masse or in part. If 
the growth is large or multiple, several repetitions of the foregoing pro- 
cedure may be required. The growth should be removed with as little 
trauma to the surrounding tissues as possible. 



OPERATION BY DIRECT LARYNGOSCOPY. 

(See Direct Laryngoscopy.) 

MALIGNANT NEOPLASMS OF THE LARYNX. 

The Lymphatic Drainage of the Larynx.— The lymphatics of the 
larynx are of clinical importance in malignant neoplasms and infectious 
diseases of the larynx. According to Most, Cunes, Boubland, and 
Green the following summary gives the essential facts : 

The lymphatic trunks which take their source from the larynx are 
derived from a network of radicles which extend throughout the lar}Tix 
beneath the mucous membrane. This network is divided by a hori- 
zontal plane at the level of the vocal cords into a supraglottic and an 
infraglottic portion. The supraglottic portion includes the lymphatics 
of the epiglottis, arytenoids, ventricular bands, ventricles, and vocal cords. 
The network of vessels is continuous throughout these areas. Over 
the upper portion and posterior surface of the epiglottis the network is 
fine and the meshes are far apart. In front and lower down, especially 
at the sides, the meshwork is denser and the strands thicker. Over the 
arytenoids, ventricular bands, and throughout the ventricular pouches 
the lymph channels are thick and closely woven. In the vocal cords, 
however, the network is very fine and more sparse than in any other part 
of the lar}Tix. The infraglottic network is finer than that above the 
vocal cords, but by no means as fine as that of the cords themselves. 
The lymph from these radicles is collected into trunks which leave the 
laryngeal cavity at certain definite places. 

In the upper part of the larynx the only place of egress is through the 
thyrohyoid membrane. The lymph vessels of the upper network 
assemble in the vicinity of the aryepiglottic folds into several trunks, 
three to six in number, which leave the larynx through the above- 
mentioned membrane near the superior thyroid artery, a corresponding 
group being on cither side of the larynx. 

These trunks course outward and backward, more or less in relation 
to the superior thyroid artery, to the carotid region, terminating in nodes 
which lie along the surface of the internal jugular vein at the level of the 



524 



DISEASES OF THE LARYXX 



bifurcation of the carotid. Tlie upper trunk of this group often runs 
backward, after emerging from the tliyroliyoid membrane, along the hyoid 
bone to the tip of the lesser, and thence outward to a node lying on the 
inferior aspect of the posterior belly of the digastric muscle. The lower 
trunks of this group may run by a lower course, outward and do^Tiward, 
into glands in the cliain lying on the surface of the internal jugular 
vein, below the lower border of the lateral lobe of the thyroid gland 
(Fig. 302). 

The collecting trunks of the infraglottic network are divided into an 
anterior and a posterior division. The anterior division consists of three 
or four small trunks, which pierce the cricothyroid membrane in the 

median line and terminate in small 
glands which lie in the median line 
at uncertain locations. The up- 
permost of these is fairly constant 
and lies in the V-shaped space on 
the cricothyroid membrane formed 
by the inner borders of two thy- 
roid isthmuses, and a third on the 
anterior surface of the trachea. 
These two are denominated re- 
spectively the prethyroid and the 
pretracheal glands. They may 
receive trunks from the anterior 
infraglottic group. Efferent trunks 
from these glands run to the be- 
fore-mentioned chain of glands 
lying on the anterior external sur- 
face of the internal jugular vein. 

The posterior division of the in- 
fraglottic collecting trunks, three 
to five in number, penetrate the 
cricotracheal membrane at or near 
the line of junction of the carti- 
laginous and membranous portions of the trachea and run into a chain 
of glands, two or five in number, which lie along the course of the recur- 
rent lar^iigeal nerve known as the recurrent chain. From these glands 
run vessels communicating with the lowermost glands of the internal 
jugular chain and a few to the supraclavicular group of glands. 

The lymphatic drainage from all parts of the larjaix thus eventually 
leads into the chain of glands lying under the sternomastoid muscle, 
along the surface of the internal jugular vein, or into the supraclavicular 
glands. The prelar^Tigeal, prethyroid, and pretracheal glands are 
merely intercepters of the current on its way to the deeper glands. 

The spread of infection or of malignant neoplasms from either the 
supracordal (glottic) or infracordal region is to the deep lymphatic 
nodes along the internal jugular vein beneath the sternomastoid muscle, 
or, in other words, to the same lymphatic system into which the tonsils 




Schema of the lymphatic flow from the supra- 
glottic and the infraglottic regions of the larynx. 
The glands of the supraglottic region flow into 
the posterior chain, while the infraglottic glands 
flow into the anterior cervical chain of glands. 
This is of diagnostic significance in determining 
if a cancer is supraglottic or infraglottic. 



MALIGNANT NEOPLASMS OF THE LARYNX 525 

drain. In infectious and advanced malignant processes of the larynx 
the deep cervical glands along the internal jugular vein and beneath the 
sternomastoid muscles are enlarged. In malignant tumors of the larynx 
such enlargement of the glands constitute a contraindication to opera- 
tive interference. 

Varieties. — Epithelioma, adenocarcinoma, and sarcoma. Of these, 
the epithelioma occurs the most frequently. Ziemssen reported 57 
epitheliomata in 68 malignant cases, while 9 were sarcomata. Bos- 
worth collected 334 cases, of which 204 were carcinomata and 130 sar- 
comata. Sir Felix Semon, in 1899, gathered the statistics of all laryngeal 
growths, amounting, all told, to 10,747 non-malignant cases and 1550 
malignant cases, 1 in 7 being malignant. 

General Facts. — It may be stated, with some confidence, that 
malignant neoplasms may be cured if operated sufficiently early. This 
is not so often done as it should be, hence the mortality rate is still 
frightfully high. The crying need of the hour is "an early diagnosis." 
How sad the comment upon medical attainments is the "fact" that but 
few practitioners are able to diagnosticate laryngeal cancer until the 
patient is in extremis. Yet how easy it is to learn one or two simple 
indications that should at least put them on their guard, and save their 
self-respect, their reputation, and the lives of their patients. 

What, then, are the early indications of laryngeal cancer f The early 
signs of cancer of the larynx are : 

(a) Continued hoarseness without cough, and without other known 
cause. 

(6) Sharp, sudden pains in the larynx, the ear, or the pharynx. 

(c) Age, the fortieth year and upward, though cancer, especially 
sarcoma, may occur at a much younger age. 

(cl) A laryngoscopic examination may show loss of movement of one 
of the vocal cords. 

The above symptoms are not conclusive, but they should arouse 
suspicion of malignancy. The practitioner may, upon the foregoing 
data, make a tentative diagnosis of a malignant growth in the l&rynx, 
and be right in nearly every instance. 

It amounts to this: A patient forty or more years old, complaining 
of continued hoarseness without cough, and with sharp, sudden pains 
through the larjoix, pharynx, or ear, should be suspected of having a 
malignant growth in the larynx. 

What other diseases cause this symptom complex? Perhaps laryngeal 
tuberculosis, syphilis, perichondritis, or rheumatic laryngitis may approx- 
imately duplicate it. There are other peculiar symptoms of these 
diseases, however, which readily distinguish them from malignant neo- 
])lasras. In rheumatism there may be sharp pains and hoarseness, but 
the symptoms are fugitive; they do not persist as in malignant neoplasms. 
In tuberculosis and syphilis a casual examination should readily enable 
the practitioner to make the differentiation. 

The extreme simplicity of the symptom complex of the early stage of 
malignant growth of the larynx encourages me to emphasize the symp- 



52G DISEASES OF THE L ART XX 

toms, as I liavt', in the ]>rec'cding paragra})lis. I wish to urge every practi- 
tioner of medicine and surgery to indeUbly impress upon his mind the 
few facts just given. Cancer of the hirynx is not a rare disease, but, on 
tlie contrary, is quite common, more than 1500 cases being on record in 
1889, and since then as many more have been (Hagnosticated and treated, 
though many have not l)een pubHshed. Inasmuch, therefore, as the disease 
is comparatively common, I desire to make plain the tentative diagnosis, 
and divest it of all complex considerations. It may be reduced to (a) age, 
forty years or more; (J)) continued hoarseness without cough; and (c) 
sudden, sharp pains in the larynx, phar^aix, or ears. 

Etiology. — The exciting cause of malignant neoplasms of the larynx 
is not clearly understood. Chronic inflammation of the larynx seems 
to be a factor, as the statistics show that families having a history of 
malignant growths are more often attacked in the lar\Tix when subject 
to chronic inflammations. Tobacco seems to act as an exciting cause. 

Mrchow tersely says that healthy tissues continually subjected to 
ii-ritations may be the seat of heteroplastic growths, and that the lar>iix, 
above all other organs, where no trace of heredity or predisposition exists, 
is apt to be the site of malignant growths. 

Age. — The age at which malignant growths of the lar^Tix appear 
varies somewhat with the variety of the cancer. Sarcoma often occurs 
in the very young. The author had a case of sarcoma in a child eighteen 
months old, which pursued a very rapid course with a fatal termination. 
It is, however, more frequent in young adult life. Epithelioma occurs 
in middle adult life and in old age; carcinoma chiefly between the ages 
of forty and sixty. 

^lalignant growths of the larynx, without reference to the variety, 
according to the following table from Gerhardt, occm- with greatest 
frequency between the fiftieth and sixtieth years. 

Cases. 

20 to 30 4 

30 to 40 18 

40 to 50 49 

50 to 60 76 

60 to 70 30 

70 to 80 10 

Total 187 

Schrotter observed carcinoma in a child of three and one-half years 
and in a girl of ten and one-half years. 

Sex. — Sex influences the formation of malignant growths to a marked 
degree, (jerhardt foimd carcinoma three times as prevalent in males 
as in females, while Semon found them in males four times as frequently. 

Social Standing. — The conditions in life seem to influence the occur- 
rence of malignant growths of the lainmx, the well-to-do being more 
often iifflicted than the poor. 

Pathology. — 'ilie ]:)ath()l()gical anatomy of laryngeal cancers is 
(piite similar to that found in carcinoma and sarcoma elsewhere in the 
body, and will not be described in detail. Under Symptoms will be 



MALIGXANT NEOPLASMS OF THE LARYNX 527 

found a brief characterization of malignant epithelial neoplasms, to 
which the reader is referred. 

Symptoms. — The chief clinical symptoms: (a) Continued hoarse- 
ness without other known cause. (6) Sharp, lancinating pains in the 
ear and pharynx, (c) Forty or more years of age. (d) Loss of move- 
ment of the vocal cord on the affected side. 

Continued hoarseness may be the only symptom for several months, 
the pain and the loss of movement of the cord coming on at a later period; 
hence, continued hoarseness, without other known cause, should, in a 
patient forty or more years of age, be sufficient to arouse suspicions as to 
the presence of a malignant growth in the larynx. While it may be said 
that a positive early diagnosis is difficult to make, it is, on the other hand, 
easy to make a provisional diagnosis and place the patient under 
observation so as to give him the advantage of the earliest possible diag- 
nosis. I make a plea, therefore, with Sir Felix Semon, von Bergmann, 
Chevalier Jackson, Otto Stein, and others for an early diagnosis. This 
alone offers a reasonable hope for the successful treatment of this 
disease. 

The hoarseness grows progressively worse, and the voice may finally 
become aphonic. 

As the edema develops, and the growth encroaches upon the lumen 
of the glottis, dyspnea, of greater or less intensity, may embarrass the 
patient. 

Cough, increasing with the progress of the disease, is usually present. 
The expectoration is at first similar to that in chronic laryngitis, and 
later is admixed with purulent secretion, and with blood in the ulcerative 
stage. 

Dysphagia, or difficult deglutition, is a late symptom in the intrinsic 
variety of the disease. If, however, the primary cancer is in the pharynx 
or the esophagus, it may appear at a much earlier period. 

The enlargement of the lymphatic glands of the neck is a late symp- 
tom, only occurring after ulceration of the tumor has taken place. 
Epithelioma is often attended by a very tardy enlargement of the glands. 
In intrinsic tumors of the larynx two sets of glands are secondarily 
aiTected — namely, the group at the angle of the jaw and those behind 
the sternocleidomastoid muscle. The subglottic glands of the larynx 
empty into those at the angle of the jaw, while the supraglottic glands 
empty into those posterior to the sternocleidomastoid muscle. If, 
therefore, the glands at the angle of the jaw are enlarged, it should arouse 
suspicion, at least, of a subglottic cancer (Fig. 302). 

The late involvement of the lymphatic glands in intrinsic laryngeal 
cancer is another argument in favor of an early diagnosis, as the tumor 
can then be easily removed in toto. Should the diagnosis be made only 
after glandular enlai'gement has taken place, the operation is a much 
more formidable one, as it necessitates the removal of the glands. Fur- 
thermore, the y)robability of total resection of either tumor or glands is 
greatly lessened in (li(> advaiiccfl stage of the disease, recurrence being 
the rule. 



528 



DISEASES OF THE LARYNX 



Laryngoscopy. — 'J'lie laryngoscopic examination ofton presents a 
picture so characteristic as to at once confirm the suspicion aroused by 
the other symptoms present. AVlien only one side is aft'ectetl, the abduc- 
tors, and possibly the adductors, are paralyzed on the affected side. 
Both sides are paralyzed when the entire larynx is involved. 

Sir Felix Semon and Rosenback have shown that the abductor nerve 
fibers degenerate earlier than the adductor nerve fibers, hence the abduc- 
tor muscle (crico-arytenoideiis posticus) is paralyzed earlier than the 
adductor (crico-arytenoideus lateralis). This phenomenon is usually 
referred to as "Semon's law." If, therefore, the case is seen early the 
abductors may be paralyzed. If, however, the case is examined at a 
later period, the degeneration will have extended to both the abductor 
and the adductor nerve fibers, and the paralysis will affect both 
the abductor and the adductor muscles. This causes the so-called 
"cadaveric" position of the vocal cords. 





Fig. 303. — Carcinoma of the right ventricular band of the larynx. It was removed by the 
intralaryngeal route by the author, returned in one year, was re-operated by the same route with- 
out relief, the patient dying two months later. (Author's case.) 

Fio. 304. — Paralysis of the thyro-arytenoidei extern! and the arytenoideus in attempted pho- 
nation, more pronounced on the left side. Drawn from author's case of subglottic carcinoma of 
the laryn.x. 



By reference to Figs. 303 and 304, illustrating two of the author's 
cases, the laryngeal image in unilateral cancer of the larynx is shown. 

The microscopic diagnosis is not always reliable, especially if the 
tissue is removed by the endolaryngeal route (W. J. Terry), as the 
cancerous growth may be deeply seated beneath the mucous membrane. 
If, however, the specimen for examination is removed by laryngofissure, 
it can be obtained from the deeper structures, and should, therefore, 
afford an accurate means of diagnosis. B. Fraenkel maintains that the 
microscopic diagnosis is of fundamental importance. Negative results 
should not, however, be taken as final, especially, if the specimen is 
obtained by the endolaryngeal route. A positive finding, however, is 
dependable if made by a competent pathologist. A globular collection 
of epithelial cells is suspicious only. Epithelial cells must be found 
where they do not belong. 'J'he irregular structure of the epithelium, 
such as is found in typical epithelial nests, is characteristic of cancer. 



MALIGNANT NEOPLASMS OF THE LARYNX 529 

When the microscopic findings include the foregoing points, a 
positive diagnosis of cancer of the epithehal variety may be made. 

Diagnosis. — Cancer of the larynx should be differentiated from 
(a) chronic laryngitis, (b) syphilitic laryngitis, (c) tuberculous laryngitis, 
perichondritis, and (d) benign neoplasms of the larynx. 

(a) Chronic laryngitis: hoarseness, while present in both chronic 
laryngitis and carcinoma, is more persistent in carcinoma. In chronic 
laryngitis the voice is husky upon arising, but becomes clear during the 
day. In chronic laryngitis of the hypertrophic variety there are discrete 
enlargements of the mucosa, but they do not have the distinct nodular 
surface present in carcinoma. In chronic laryngitis the vocal cords are 
freely movable in both abduction and adduction, whereas, in carcinoma 
one or both cords are immovable. 

(b) In syphilitic laryngitis the hoarseness is low-pitched, and brassy 
or raucous in character. In carcinoma of the larynx it is higher pitched, 
and softer in character; indeed, it may become aphonic in the later stages. 
The cords are freely movable in syphilitic laryngitis, and the history of 
the case usually clears the diagnosis. 

(c) Tuberculous laryngitis is characterized by hoarseness and pain, 
and when perichondritis is present, by fixation of one or both vocal 
cords. The history and the examination of the sputum render the 
diagnosis so plain that there can be but little room to suspect malignancy. 

(d) Benign neoplasms of the vocal cords (the most frequent site of 
intrinsic malignant neoplasm) are characterized by hoarseness, though 
pain and paralysis of the laryngeal muscles are absent. 

Prognosis. — The general prognosis of malignant growths of the 
larynx is bad. This would not be so if an earlier diagnosis were made. 
In other words, the prognosis depends in a large measure upon the early 
recognition and surgical removal of the diseased tissue. Sir Felix 
Semon claims 90 per cent, of cures by thyrotomy. All, or nearly all, of 
his operated cases were diagnosticated and operated in the early stage, 
hence the high percentage of cure^. Jackson, in a total of 9 complete 
laryngectomies, including the epiglottis, had but 1 death immediately 
following the operations. The others lived eight or more months after 
the operations. 

Gluck in his first 10 cases reported 2 as cured (three years without 
recurrence). In his last series of 22 cases 1 died, making a percentage 
of recoveries higher than Semon's. Of a total of 23 complete laryn- 
gectomies he claims 3 good results. In 1903, out of 125 cases, he 
claimed he could show 38 living cases, the oldest still alive and in good 
condition thirteen years after the operation. 

Of those dead, some lived eleven, eight, six and one-half, five and 
one-half, four and one-half, and three and one-half years. Some died 
of illness other than recurrence. 

Kocher in 12 cases had 6 recurrences. White and Powers, after 
reviewing a large nuinber of cases, conclude that in complete laryngec- 
tomies the death rate is 35 per cent., while in partial laryngectomies it 
is about 27 per cent. 
34 



530 DISEASES OF THE LARYXX 

Werckmeister collected 297 cases of complete laryngectomy, of which 
36 were fatal, by which he probably means that 36 died during or 
soon after the operations. How many died later from recurrence is 
probably not shown in these figures. 

In a collection of 105 cases operated i)y laryngofissure, 4 died of pneu- 
monia within eight days. The low death rate from this cause stamps 
the procedure as safe from a surgical standpoint. The voice after 
laryngofissure varied with the extent of the operation. In benign 
tumors it usually remains fair or good. In malignant neoplasms, as 
they generally affect the integrity of one or both cords, it is not so good. 
If only one cord is involved, a useful voice is retained in simple laryngo- 
fissure and in hemilaryngectomy. 

In summing up the prognosis under operative treatment, it may be said: 
(a) That in those cases diagnosticated and operated in the early stage, 
before ulceration and extension to the neighboring parts, the prognosis 
is good. (6) In those cases operated in the late stages the prognosis is 
bad. (c) The personality of the operator and the fortunate opportunity 
of seeing the cases in an early stage favor a better prognosis, (d) Laryngo- 
fissure gives a better chance of recovery when the disease has not extended 
to the extrinsic parts of the larynx, (e) Total laryngectomy is attended 
by greater shock and a higher mortality than the more limited operations. 
It should be remembered, however, that this method of operating is 
usually adopted in the more advanced and hopeless cases. (/") Kei- 
shaber has divided cancer of the larynx into two clinical groups, which, 
from the standpoint of prognosis and treatment, is important, namely: 
(1) Intrinsic cancer of the larynx, and (2) extrinsic cancer of the larynx. 
Intrinsic cancer has its origin in the vocal cords, the ventricular bands, 
and the ventricular pouches. Extrinsic cancer of the larynx arises from 
the arytenoid cartilages, the epiglottis, and other parts contiguous to 
the larynx. In intrinsic cancer the growth develops slowly and extends 
with extreme reluctance by metastasis to the lymph glands behind the 
sternocleidomastoid, and to the neighboring tissues surrounding the 
larynx. 

In the extrinsic variety the reverse of the above facts is true. In 
other words, the prognosis in intrinsic cancer of the larynx is naturally 
much more favorable than it is in the extrinsic variety. To make 
accurate deductions from the statistics of cancer of the larynx it is neces- 
sary to know whether it is intrinsic or extrinsic, sarcomatous (for it is 
much more favorable in this variety) or carcinomatous; whether operated 
in the early, middle, or late stage; whether by laryngofissure, partial laryn- 
gectomy, hemilaryngectomy, complete laryngectomy, or by ligation and 
resection of the external carotid arteries and their branches as advo- 
cated by Dawbarn. 

The foregoing data fairly represents the prognosis under existing 
methods and conditions, though I mistrust it presents it in a too favorable 
light. 

Frank Hartly, in 1902, reviewed the literature from 1833, when Brauers 
performed the first thyrotomy, and the first laryngectomy by Watson 



MALIGNANT NEOPLASMS OF THE LARYNX 531 

in 1878, down to the more improved methods of operating in 1800. The 
death rate withm the first days after the operation, up to 1889, for 
laryngectomies was 44 per cent., and of those remaining cured for three 
years, prior to 1889, it was 7 per cent. Since 1889 the death rate within 
the first ten days has been 8.5 per cent., in those remaining cured, 15 
per cent. The following tabulation shows the improvement in the 
immediate and the remote death rate and the net gain in the mortality: 
Death rate in laryngectomies for every one hundred operations. 

Immediate deaths. Remote deaths. Total deaths. Living. 

Per cent. Per cent. Per cent. Per cent. 

Prior to 1889 44.0 52.0 96.0 4.0 

1889 to 1900 8.5 47.5 56.5 44.0 

The present total death rate, before the end of the third year, is 56 
per cent., as against 96 per cent, prior to 1889. The tremendous im- 
provement in the mortality rate is encouraging, and stands as the strongest 
argument in favor of still further improving the surgical technique for 
the cure of this dread disease. It should be remembered, however, 
that the improved mortality rate following the surgical treatment is 
largely due to the more intelligent selection of cases, as well as to the 
improved technique and asepsis now in vogue. In the period prior to 
1889 the failure to elect the proper method of operating probably largely 
contributed to the high death rate. There is still room for improve- 
ment in this regard, and it is to be hoped that in the near future a still 
lessened mortuary report will be given. 

Pean reports a case of extirpation of the larynx and part of the esopha- 
gus for a cancerous tumor diagnosticated by laryngoscopic examination. 
Although apparently limited to the left side, it was found to extend to 
the right side, and to the upper portion of the esophagus, the hyoid bone, 
and the base of the tongue. The whole mass was removed, and, to com- 
pensate for the extensive loss of substance, the esophagus was drawn up 
and stitched to the skin in the upper angle of the wound. The trachea 
with a cannula inserted in it was also secured by suture to the skin. An 
artificial larynx was supplied, which not only enabled the patient to 
swallow, but also allowed him to inhale air physiologically prepared in 
passing through the nose. 

Pean draws the following conclusions from the case : 

1 . That it is impossible, prior to operation, to be certain of the extent 
of the disease when no subjective .symptoms are present. 

2. That the surgeon must never promise beforehand to limit the opera- 
tion to the removal of only a part of the larynx. 

3. That an extensive operation, including the removal of the hyoid 
bone and the base of the tongue, may be undertaken with safety and 
success. 

4. That after siicli oixTiilious, inij)()rtinit inodilicjitious of the anatomy 
of the parts ()j)erate(l on alwavs follow, the abnormal openings of the 
trachea and the esophagus being raised, and the epiglottis and the root 
of the tongue being lowered. 



532 DISEASES OF THE LARYXX 

5. That, thanks to suitable mechanical appliances, the functions of 
the parts can be, to a large extent, restored, even after the most ex- 
tensive operations. 

Treatment. — The various methods of treating laryngeal cancer may 
be appropriately studied under the following heads: 

1. The endolarvngeal route. 

2. Laryngofissure or thyrotomy. 

3. Subhyoid pharvngotomy. 

4. Partial laryngectomy or hemilaryngectomy. 

5. Complete laryngectomy. 

6. Ligation or injection of the external carotids and their branches. 

7. Tracheotomy. 

Each of the foregoing methods of treatment has its advocates and, in 
selected cases, its advantages. I shall endeavor to point out the most 
prominent indications for each in such a way as to enable the surgeon 
to elect the one best suited to the case in hand. 

1. The Endolarsmgeal Operation. — The endolaryngeal operation for 
cancer of the larynx is not unlike that described for papilloma of the 
larynx (pp. 521 and 522). The responsibility attending it is, of course, 
much greater on account of the gravity of the disease. The most dis- 
tinguished advocate of this method of operating is B. Fraenkel, who 
cured three cases by operating on them by the endolaryngeal route at 
intervals covering a period of five years. At the time of his published re- 
port there had been no recurrence after two years of quiescence. I have 
operated on a few cases by this method, in 1 of which there was recurrence 
in ten months, with pronounced hoarseness, dyspnea, pain and cachexia. 
The second operation did not relieve him as did the first. He gradually 
grew worse, and died two months after the second operation. The second 
operation was performed twelve months after the first. The case (Fig. 
303) should have been subjected to hemilaryngectomy or complete 
laryngectomy at the time of the first operation, notwithstanding the fact 
that the tumor was apparently accessible to the double cutting forceps 
via the mouth. It is quite probable that I did not succeed in removing 
all the cancerous tissue, which I could have done had I resorted to an 
operation by the external route. Notwithstanding the brilliant results 
reported by B. Fraenkel, I think the endolaryngeal operation should 
rarely be the operation of choice. It may be chosen when other methods 
are refused. Direct laryngoscopy promises better results than are 
obtained by the indirect method. Laryngofissure may be performed, 
a pathologist being present to make an examination of the specimen by 
the freezing method, which only requires a few minutes. In Figs. 305 
and 306 is shown the author's cases of pedunculated carcinoma of the 
larynx. This is a rare condition, and I know of only two similar cases 
on record (B. Fraenkel). The glands of the neck were large and firm. 
A gland was first removed and submitted to microscopic examination 
and carcinoma was rej)orted. The laryngeal neoplasm was then removed 
with a snare. As the patient swallowed the growth, warm salted water 
was given and the tmnor ejected. The patient, aged forty-five years, 



I 



MALIGNANT NEOPLASMS OF THE LARYNX 533 

died eighteen months later, metastatic carcinomata being found post- 
mortem in the Kver, spleen, and stomach. 

The operation may then be completed by the method thought best in 
view of the macroscopic and microscopic findings. The precise location 
and extent of the growth, whether intrinsic or extrinsic, should also 
be determined after the larynx is opened by laryngofissure. 

In order to render the thorough examination of the parts through the 
laryngofissure possible, the interior of the larynx should be brushed or 
sprayed with a 5 per cent, solution of cocaine to abolish the reflexes. 
Adrenalin, 1 to 1000, may be used to shrink the mucous membrane, and 
thus bring the limitations of the growth into greater prominence. 





Fig. 305. — The author's case of pedunculated carcinoma of the larynx growing from the left 
ventricular band. The timaor was distinctly movable. It was removed with a cold-wire snare 
through the mouth. The patient swallowed it, was given warm salt solution, after which he ejected 
it, and the rare specimen was thus preserved. A gland was pre^aously removed from the corre- 
sponding side of the neck, and upon microscopic examination by the Colmnbus laboratories it was 
pronounced carcinoma. The laryngeal tumor was likewise submitted and pronounced carcinoma. 
Peculiar interest attends the case on account of the distinct segregation of the tumor from the 
surrounding tissues and its pedicle attachment. 

Fig. 306. — View of the inferior surface of the author's case of pedunculated carcinoma of the 
larynx in a man aged forty-five years. The peduncle was tubular and composed of mucous 
membrane, and was attached to the ventricular band of the left side. The tmnor was freely 
movable in the larynx, occasionally obstructing the breathing. The tumor presented the appear- 
ance of a gland dislocated beneath the mucous membrane. 

2. Laryngofissure or Thyrotomy. — ^This operation is one that should 
be chosen more often for obtaining a specimen for examination and for 
the removal of cancerous and benign growths. 

The indications: (a) For the removal of foreign bodies lodged in the 
ventricular pouch which cannot be removed by either the direct or 
indirect endolaryngeal route. 

(b) For the removal of benign neoplasms which cannot be readied 
successfully by the endolaryngeal route. 

(c) To obtain a specimen from a suspected malignant ne()])lasm of 
the larynx, for microscopic examination, especially when tlu> one re- 
moved by the endolaryngeal route gives a negative result. 



534 DISEASES OF THE LARy^'X 

(d) To expose the interior of the larvnx to view in order to determine 
the gross aj)j)earance, site, and extent of a laryngeal neoplasm, pre- 
liminary to the election of the method of removal. 

(e) As a method of election for the removal of an intrinsic malignant 
growth of the larynx. 

When should lari/ngofi.'isurc he tite meihod of choice or election in malig- 
nant neoplasms f 

(f) When, upon larvngoscopic examination, the growth is found to be 
limited to the soft parts or to a small area, and can be removed through 
the laryngofissure, with the sacrifice of but little or none of the carti- 
laginous framework of the larynx. 

{g) When, upon laryngoscopic examination, the growth, while some- 
what extensive, does not appear to involve the deeper tissues, and can in 
all probability be entirely removed by laryngofissure. 

(h) When the growth is somewhat more extensive than in (/) and 
(g), but is still circumscribed within a fractional part or one-half of the 
larynx, having its origin from one cord, or the ventricular pouch or band, 
is not ulcerated, and there is no enlargement of the glands posterior to the 
sternocleidomastoid muscle. 

(i) When the growth is intrinsic, the vocal cord, the ventricular pouch, 
or the ventricular band, even though it is c^uite large, and the lymphatic 
glands posterior to the sternocleidomastoid muscle are not enlarged, it 
is barely possible that operation by laryngofissure may be successfully 
done. If the growth has involved the cartilaginous framework of the 
larynx to such an extent as to necessitate the removal of a considerable 
portion of it on one side, laryngofissure should not be the method of 
choice. Hemilaryngectomy or incomplete laryngectomy should be 
chosen after a preliminary laryngofissure. 

Axiom: Laryngofissure should be the operation of choice when the 
malignant neoplasm is intrinsic, and when diagnosticated in the early 
stage. 

Laryngofissure or thyrotomy has been frequently referred to as a 
method of removing growths, foreign bodies, and obstructive lesions of 
the larynx. It will be described in this connection and cross-reference 
made to it wherever the author thinks it is the proper procedure for 
other affections. 

Technique. — The operation consists in splitting the larynx in the 
anterior median line and removing the growth through the fissure thus 
made. It is not a formidable procedure, and should be done much 
oftener than it is. 

(a) The preparation of the patient: In this, as in all cases where a 
general anesthetic is to be administered, the patient should be placed in 
a hospital twenty-four to forty-eight hours before the time of operation. 
Broken doses of calomel, followed by a saline cathartic the following 
morning, should l)e administered in time to produce a free evacuation of 
the bowels a few hours before the operation. The patient should be 
given no food within nine hours of the operation. 

(h) The preparation of the field of operation: The neck should be 



MALIGNANT NEOPLASMS OF THE LARYNX 



535 



scrubbed and shaved twelve hours prior to the operation, and a moist 
carboHc dressing placed over the laryngeal region and held in position 
with a bandage. The scrubbing should be repeated after the patient is 
under the influence of the anesthetic. 

(c) Anesthesia: Rectal anesthesia, as practised by Cunningham, of 
Boston, and Stucky, of Lexington, is performed by the administration of 
the vapor of ether with Cunningham's apparatus. It combines simplicity 
and safety, a small amount of ether being used, and there is no nausea 
and vomitmg following its administration. The method is especially 
useful in operations about the head, as the anesthetist is removed from 
the field of operation. In throat 

operations it is especially recommend- Fig. 307 

ed, as the anesthesia may be admin- 
istered throughout the operation and 
the secretions are not stimulated by its 
administration. 

(d) The cutaneous incision: The 
incision should be made in the ante- 
rior median line, and should extend 
from the os hyoides above to the ensi- 
form cartilage below (Fig. 307). There 
are but few structures of importance 
encountered in this region, excepting 
a small amount of areolar tissue and 
the anastomosis of the inferior laryn- 
geal arteries in the median line. These 
arteries are encountered at either the 
inferior border of the thyroid carti- 
lage or the superior border of the 
cricoid cartilage, hence it may not be 
necessary to cut them, as they can be 
pushed aside. There are no serious objections to severing them, but if 
this is done it is better to locate them and tie them off with absorbable 
catgut on either side of the median line before dividing them. The 
venous oozing may be controlled by pressure, or, if too profuse, the 
venous trunks should be ligated. 

(d) The incision of the thyroid cartilage : This should be done in the 
median line with knife or scissors (Fig. 308). The knife is preferable 
unless the cartilage has become ossified, as the dissection can be carried 
to the mucous membrane without cutting it. This is important, as the 
incision through the membrane at the anterior commissure of the glottis 
should be exactly in the median line. If it is not, one of the cords will be 
injured. 

(e) The incision through the nuicous membrane: First locate the 
median line at the anterior commissure. If in doubt, begin the incision 
at the upper limit of the wound, and cut downward to the anterior 
commissure. The knife should then be inserted through the incision and 
between the cords, and the incision at the commissure made from within 




The line of incision for the complete or 
partial removal of the larynx. 



536 



DISEASES OF THE LARYXX 



outward. In this way the cord.s will not he injured. The incision is 
then extended to the lower limit of the thyroid cartilage. 

(/) The larynx should then he opened" bv retracting the two tlivroid 
cartilages from the median line (Fig. 309). This is done by the assistants 
with retractors. 



Fig. 308 



Fig. 309 





Fig. 308.— Laryngofissure. Tracheotomy has been performed, a cross-puncture at the lower 
border of the thyroid made, and the scissors blade introduced through it preparatory to making 
the mcision through the anterior commissure of the thyroid cartilages. (After Moure.) 

Fig. 309.— Laryngofissure (thyrotomy) completed, the tumor exposed ready for removal. (After 



(c/) The removal of the growth: Having completed the larvngofissure, 
and having separated the incised thyroid cartilages, the location and 
character of the growth should be studied. The growth may be re- 
moved through the laryngofissure with a snare, scissors, or knife. The 
better surgical procedure is with the knife or scissors, as with either of 
these instruments the scope of the operation is entirelv under the control 
of the oi)erator, whereas with the snare the depth of' the cut cannot be 
accuratelv controlled. 



MALIGNANT NEOPLASMS OF THE LARYNX 537 

(h) Hemorrhage: The hemorrhage in the preHminary part of the 
operation, i. e., the laryngofissure , is comparatively sKght, as it is con- 
trolled by pressure and ligatures as the bleeding points appear. In the 
removal of the growth, however, there may be considerable hemorrhage 
both during and after the operation. This is easily controlled with 
artery forceps or with the actual cautery applied to the bleeding areas. 
The hemorrhage occurring after the patient becomes conscious is expec- 
torated, and causes little or no trouble. During the operation the patient's 
head should hang over the end of the table, the table also being lowered 
at the head end, to prevent the blood being aspirated into the lungs. 

(i) The closure of the laryngofissure: Having removed the neoplasm 
(or foreign body), the thyroid cartilages are reunited with an absorbable 
ligature. The coaptation of the cut edges of the cartilages should be 
carefully done. If, for instance, one side is higher than the other the 
vocal cords at the anterior commissure will not approximate on the same 
level, and vocalization will be somewhat modified. 

{]) The closure of the cutaneous wound: This should be done with 
simple sutures about one-fourth of an inch apart, and the whole covered 
with plain sterile gauze. At the end of from three to six days the stitches 
should be removed. At this time the wound should be thoroughly 
healed, little additional attention being required. 

3. Subhyoid Pharjmgotomy. — Subhyoid pharyngotomy for the removal 
of malignant neoplasms of the larynx is rarely used. There are cases, 
however, when it should be elected for this purpose in preference to any 
other method. 

The indications: The indications for subhyoid pharyngotomy are 
few, and are chiefly in connection with extrinsic malignant neoplasms 
of the larynx, and in cases complicated by extension to or by origin in 
the pharynx. They are as follows. 

(a) When the growth is situated in the epiglottis or other of the higher 
portions of the larjmx, and which for any reason cannot be thoroughly 
removed by the endolaryngeal route. 

(b) ^N]len the growth is situated in the upper portion of the larynx 
and has extended to the pharyngeal wall. 

(c) When the malignant growth begins in the pharynx and extends to 
the supraglottic (extrinsic) portion of the larynx. 

Technique. — (a) Place the patient under chloroform or ether anesthesia 
per the rectum or mouth after the usual preliminary preparations. 

(/;) Prepare the neck and face by scrubbing, etc. 

(c) Elevate the shoulders of the patient by placing a sand pillow under 
them, and draw tlie head well l)ackward so as to bring the hyoid region 
into easy access. Also elevate the foot of the operating table to preveut 
blood and secretionsi entering the trachea while the reflexes are a])oh!shc(l 
l)y the anesthetic. , : 

((/) Make a transverse incision througli the skin after Kocher's metliod, 
l)eginning about v inch below the inferior border of the hyoid bone, 
extending it from the anterior border of the sternocleidomastoid 
muscle to tlie corresponding point on the opposite side of the neck. 



538 DISEASES OF THE LARYXX 

The incision should l)e from 2^ to 3 inches in length. Then make a 
perpendicular incision in the median line, beginning above at the trans- 
verse incision, and extending downward to the prominence of the thyroid 
cartilage. 

(e) Divide the superficial fascia, in which the anterior jugular vein 
is found. The jugular vein should be ligated in two places on each 
side of the neck antl severed between the ligatures. 

(/) Sever all the muscles, including the sternohyoid, on either side of 
the median line, and just beneath them, the thyrohyoid muscles thus 
exposing the thyrohyoid membrane to view. 

(g) With the finger applied to the membrane explore for the epiglottis, 
so as to avoid injuring it in the next step of the operation. 

(h) Incise the thyrohyoid meml)rane, thus exposing the diseased area 
to inspection. 

(/) Carefully inspect the deeper field, beginning at the anterior surface 
of the epiglottis, for evidences of malignant growth. 

(;") Seize the epiglottis with toothed forceps, and gently draw it out- 
ward through the wound, securing it with either a suture through its 
tip or with locked forceps. 

(k) Traction upon the epiglottis opens the wound and exposes the 
deeper parts to view. 

(/) Through the opening all diseased tissue is removed with scissors, 
knives, and double cutting forceps, some of the surrounding healthy 
tissue being also included. 

(m) The wound is now closed by suturing the thyrohyoid membrane, 
the muscles, and the superficial fascia with absorbable catgut, and the 
skin with non-absorbable ligatures. 

(w) The external wound should be dusted with iodoform 1 part and 
boric acid 4 parts, and a gauze dressing applied. 

(o) The dressing should be removed in three to five days and renewed. 
The stitches in the skin should be removed on about the fifth or sixth day. 

(p) At the end of ten or twelve days the patient should be up and able 
to leave the hospital. 

4. Partial Laryngectomy. — This operation is often spoken of in litera- 
ture as synonymous with laryngofissure, which is but the preliminary 
step in partial and hemilaryngectomy. Partial laryngectomy is a more 
extensive operation than simple laryngofissure. In laryngofissure only 
the soft parts and the growth are removed, whereas in partial laryn- 
gectomy a portion of the cartilaginous framework is removed with the 
growth. 

Indications. — The indications for partial laryngectomy are somewhat 
difi'erent from those for laryngofissure. For example, it is not indicated 
for the removal of foreign bodies in the larynx, benign neoplasms, or 
in cancerous growths which only involve the soft structures. The 
following are the chief indications: 

(a) In malignant growths seeming to be limited to the soft parts on 
one side of the larynx, and in wdiich it is suspected the cartilage is also 
involved, a partial laryngectomy may be done. 



MALIGNANT NEOPLASMS OF THE LARYNX 539 

(b) In malignant growths limited to one side, and which involve a 
portion of the cartilaginous framework of the larynx. The removal of 
the growth and the portion of the cartilage involved is regarded as suffi- 
cient to obliterate all traces of the growth. If partial laryngectomy will 
not obliterate the growth, complete laryngectomy should be performed. 

(c) If, for any reason, there is a suspicion of involvement of the deeper 
structures, partial laryngectomy is indicated. 

Technique. — The technique is so little different from that given in 
laryngofissure that a detailed description is unnecessary. The chief differ- 
ence consists in the removal of the affected portion of the cartilaginous 
framework in addition to the procedures practised in laryngofissure, in 
which only soft tissues are removed. The additional fact that partial 
laryngectomy is usually indicated in extrinsic cancers also implies a 
more serious condition, with earlier glandular involvement. Hence, the 
anxiety and desire to be certain to include all the diseased tissue, even 
at the expense of some healthy tissue. 

5. Complete Laryngectomy. — ^The removal of the larynx is a formidable 
and sad procedure. The death rate in the hands of the average operator 
is high. The condition of the patient, should he recover from the opera- 
tion, is often pitiable indeed, though this fact does not always appear in 
the published reports. However, from the patient's point of view he 
would rather be alive without his larynx than dead with it. Complete 
laryngectomy may, therefore, be done when simple and less radical 
measures hold out little or no hope of success. 

Indications. — In a general way it may be said that the total removal 
of the larynx is indicated in those cases in which the disease involves a 
large portion of the structures, soft and cartilaginous, in both lateral 
halves of the larynx. It may also be indicated when one side is involved 
in its entirety and there is a strong suspicion that it has also invaded the 
opposite side. The following classification fairly represents the chief 
indications for complete laryngectomy : 

(a) The involvement of one-half of the larynx, with a strong suspicion 
that it has invaded the opposite side, the glands of the neck not being 
involved. 

(b) The involvement of both sides of the larynx, especially if the carti- 
laginous framework is included in the process, the glands of the neck not 
being involved. 

(c) The involvement of the extrinsic areas of the larynx on both sides. 
If the intrinsic portions only, as the vocal cords, are invaded by the 
cancerous growth, it might be successfully operated by laryngofissure. 

{d) The involvement of the extrinsic portions of the larynx on both 
sides, together with the contiguous tissues, as the pharynx, calls for 
the total extirpation of tlie larynx together with the other structures that 
are cancerous. 

(e) When both sides are extrinsically more or less involved, together 
with the glands of the neck, total laryngectomy and the ablation of all 
the lymphatic glands on botii sides of the neck ai'c indicalcd, though a 
fatal result will probably follow. 



540 



DISEASES OF THE LARYXX 



Technique. — The method of \\'. W. Keen is prohahly the simplest, 
safest, and most thorough yet devised, and is the one used by me. It is 
given in the following analysis: 

(o) The preparation of the patient for the operation bears an impor- 
tant relation to the success or failure of the surgical procedure 
If the patient's general health is had the prognosis is correspondingly 
had. It is essential, therefore, that the general condition of the 
patient he improved hy a short course of forced feeding and tonic 
remedies. The o})eration should he performed in the morning, when the 
vital forces are at their best. On the evening prior to the operation a 




The superficial soft tissues dissected from , the larynx preparatory to the complete removal of 
the carcinomatous larynx. The remaining soft tissues should be dissected from the larynx before 
separating the posterior wall of the larynx from the esophagus. 



cathartic should be given, and, if necessary, a saline given early tlie fol- 
lowing morning. The face (adult male) and neck should be shaved and 
scru])be(l the day before the operation, and a moist carbolic acid dressing 
a])j)lied. 

(h) On the following morning the patient should be placed upon the 
o])erating table in the Trendelenburg position, with the foot of the table 
raised to prevent the aspiration of blood into the trachea. The patient 
should be kept in this p(xsition throughout the operation, and for three 
days after it. 

(c) Ether vapor, ])er rectum, as recommended by Cunningham and 



PLATE VIII 




Arteries of the Larynx. The Superior Laryngeal and tlie 
Inferior Laryngeal arteries, branches of the superior and inferior 
thyroid arteries, respectively, supply the \A^al]s, glands, muscles, 
and mucous membrane of the larynx. 



MALIGNANT NEOPLASMS OF THE LARYNX 



541 



Stucky, is, perhaps, the best method of inducing anesthesia, as the anes- 
thetist and his apparatus (Cunningham's) are removed from the field of 
operation. 

The anesthetic may be administered by the mouth or the tracheotomy 
tube (in case a preliminary tracheotomy has been performed), or, if 
tracheotomy is performed during the operation, it may be given by the 
mouth until tracheotomy is performed, and then through the tracheotomy 
tube. 

If tracheotomy is not done either before or during the operation, the 
anesthetic may be given by mouth until the trachea is severed from the 
cricoid cartilage, and then through the stump of the trachea. 

(d) The incision should be made in the median line, beginning at the 
hyoids and extending downward to the ensiform cartilage (Fig. 307). 





Fig. 311. — Carcinoma of the larynx removed by c'omplete laryngectomy. Poste: 
(Author's case.) 

Fig. 312. — Carcinoma involving all of one and part of the other lialf of the larynx. 
laryngectomy was performed by the author by Keen's method without tracheotomy. 
view. (Author's case.) 



Complete 
Anterior 



The only vessels of any consecpience encountered are the superior and 
inferior laryngeal arteries and their branches. The arteries and veins 
should be ligated as they are exposed (Plate VIII). The venous hemor- 
rhage may i)e controlled by pressure, or the larger trunks may be tied. 

(e) Separate the soft structures (Fig. 310), including the muscles in 
the median line, and dissect them from the larynx down to the esophagus 
on the posterior wall of the larynx. 

(/) Introduce a heavy anchor suture between tlie first and second 
cartilaginous rings of the trachea on either side, and pass one end of the 
suture through the adjacent skin, as shown in Fig. 313. This is done to 
prevent the trachea dropping into the nud'asl juiin when i( is .severed 
from the larvnx. 



542 



DISEASES OF THE LARYNX 



(g) Tie the anchor sutures descrihed in the preceding paragraph, and 
sever the trachea from the cricoid ring of the larvnx with a sharp scalpeh 
If the anesthetic has l)een given l)y the mouth, it should l)e transferred to 
the trachea.^ 

(h) Dissect the posterior wall of the larynx from the esophagus with 
the finger or blunt instrument, as shown in Fig. 313. This is often a 




Cuiuplete laryngectomy. The larynx has been severed from tlie trachea at the junction of 
the first ring and the cricoid cartilage. T\\e larynx is being seiiarated from the anterior wall 
of the esophagus by blunt dissection. 



difficult task, as the adhesions are firm. Every ett'ort should be made to 
avoid tearing the wall of the esophagus, as it is difficult to repair it by 
suture. 

(?') Having separated the esophagus from the larynx as high as the 
arytenoid cartilages, it should be severed from the larynx by transverse 
incision (Fig. 315). 

(j) The only attachment remaining is the thyrohyoid membrane in 



' In this description it is presumed that the removal of the larynx is done without tracheotomy 
either prior to or during the operation, as suggested by Dr. W. W. Keen. I performed the opera- 
tion in this manner in August, 1905, with satisfaction. The larynx and carcinoma thus removed 
are shown in Figs. 311 and 312. The patient died six days after the operation from exhaustion. He 
rallied after the operation, progressed very favorably for five days, took food per rectum for four 
(lays, and by mouth for one. He was then unable to retain food on his stomach. Rectal feed- 
ing was again tried, but was not retained. Death occurred the following day. The patient was 
fifty years old, and had been a heavy whisk.y drinker for twenty-five years. The carcinoma was 
extrinsic and large, and while chiefly limited to the right half of the larynx, it had extended to 
the left side of the epiglottis. Tnere was no enlargement of the glands of the neck. Only one 
enlarged lymphatic gland was found, and that was in the glosso-epiglottic space. 



MALIGNANT NEOPLASMS OF THE LARYNX 



543 



front. This should also be severed by a transverse mcision (Fig. 315). 
The larynx and the neoplasm are thus extirpated, leaving the pharynx 
open in front. 

(A') The lower pharyngeal membrane should now be sutured to the 
thyrohyoid membrane below the hyoid bone, as shown in Fig. 315, thus 
closing the wound in the anterior wall of the pharynx. 

(/) The soft tissues should be brought together in the median line 
by buried absorbable catgut sutures. 

(m) The stump of the trachea should be securely sutured to the skin, 
as the breathing must in future be carried on through it. 

(n) The skin should be closed by sutures except around the stump 
of the trachea, as shown in Fig. 316. 




Complete laryngectomy. The thyroid glands turned aside with ligatures through them. The 
trachea severed below the cricoid cartilage preparatory to dissecting the larynx from the esoph- 
agus and other deep soft tissues. Anchor sutures passed through the upper ring of the trachea 
to prevent the trachea dropping into the mediastinum, a, thyrohyoid membrane. 



(o) A dressing should be applied over the line of skin sutures. A 
thin dressing of gauze should be placed over the tracheal stump to filter 
the air inspired through it. This portion of the dressing should be 
fref|uently changed, as it becomes soiled by the secretions coughed out 
through the trachea. 

Affcr-treatment.— Keep the foot of the bed elevated a foot or more 
for three days, to favor the drainage of the trachea, or until tlie patient 
can take food by the mouth. Sustain the patient by rectal feeding at 
intervals of three or four hours for four days. At the end of this time 
the pharyngeal wound is usually united, and food maybe given by mouth. 
In from twelve to fourteen days the patient should be able to leave the 
hospital, if he is not dead. 



544 



Disi:Asr:s of the laryxx 



Axioms. — 1. Earlv diat'iiosis and an early operation in laryngeal 
cancer means a prohable cure. 

2. An early provisional diagnosis of cancer may be made if three 
clinical facts are borne in mind, namely, a patient forty or more years old, 
complaining of continued hoarseness without cough, with sudden sharp 
]iains in the larynx, pharynx, or ears. 

3. The operaticm of choice should be the one that will ensure the com- 
plete removal of malignant tumor with the least destruction of normal 
healthv tissue and the least damage to function of the larvnx. 




larynKect 
wall of th 



The larynx has been rein()\e( 
iix. The sutures are in positio 



leaving an opening in the anterior 
really to close the wound. 



4. Intrinsic cancer of the larynx is successfully operated by laryngo- 
fissure, a simple and comparatively safe method. 

5. (^omplete removal of the larynx is a formidable and dangerous 
o|)eration, only suited to extensive involvement of the soft and the carti- 
laginous portions of the larynx in both lateral halves. 

(). Extensive involvement of the larynx and of the adjacent structures 
means certain death without an operation, and probable death with an 
operation. 

7. If the diagnosis of cancer of the larynx is only made at an advanced 
stage, tlie phvsician is guilty of " ignorance," when it is easy to be "wise." 

Postoperative Considerations. — The surgeon's responsilnlities are by no 
means ended when the operation is completed. There are several 



MALIGNANT NEOPLASMS OF THE LARYNX 



545 



conditions present or liable to arise that demand his thoughtful attention. 
Among them are the following: 

1. Shock and Sudden Death. — Stoerk attributes death by shock to the 
severing of the fibers of the inhibitory cardiac branches of the pneumo- 
gastric nerve. They are given off, and pass forward to the larynx, 
thence downward back of the trachea, where they are liable to injury in 
separating the esophagus from the larynx and the trachea. It is, there- 
fore, well to keep close to the posterior wall of the trachea, and to avoid 
undue manipulation and traumatism in making the separation. 

Crile, by experimentations upon lower animals, arrives at the conclu- 
sion that sudden death in laryngectomy and intubation, is due to an 
irritation of the middle and the upper portion of the larynx, the irritation 




ifter complete laryngectomy. The end of the trachea is sutured to the skin. 



exciting a reflex inhiljition of the cardiac branches of the pneumogastric 
nerve. He therefore recommends a preliminary incision through the 
cricoid memjjrane, through which the interior of the larynx may be 
brushed with a 5 per cent, solution of cocaine. After that is done the 
operation of election is continued. He also suggests that an injection 
of atropine helps to prevent the reflex influence upon the heart. He 
makes the following distinctions between asphyxia and reflex action on 
the respiratory organs and the heart: 

(a) In asphyxia there are more or less violent eftorts at breathing, the 
heart momentarily beating stronger; wliereas, 

(b) In reflex disturl)ances the breathing stops suddenly and the heart 
immediately l)ecomes weak. 

The above distinctions are peculiarly applicable to impending death 
35 



546 DISEASES OF THE LARYXX 

(liiriiifj intubation in diphtheria and pseudomembranous croup. During 
intubation the patient is suddenly asj)hvxiated, or is thrown into a state 
of shock, the characteristics of each lieing given in the above paragraph. 
Treafmcnt of Cardiac Rrjicxes. — (a) Instantly lower the head without 
further manipulation of the lar^^lx. 

(b) Slap the chest with a cold wet towel, then immediately dry the 
surface and repeat the cold applications. 

(c) Artificial respiration should, in the meantime, be kept up. 
Treatmcni of Asphyxia. — (a) Remove the intubation tube or the 

obstruction to the larynx and clear it of membrane. 

{h) The patient will then, in all probability, cough out more membrane 
or obstructing secretions, thus clearing the lumen of the trachea. 

(c) Re-introduce the cannula (in diphtheria), and no further trouble 
will likely occur. 

AViiile the foregoing remarks upon shock and sudden death do not, in 
all respects, have a direct bearing upon the operation for cancer of the 
larynx, they nevertheless have an indirect relationship, and may prove of 
value in the study of this subject. 

2. Inspiration pneumonia is a common sequel of the operative treat- 
ment of laryngeal cancer, and is a frecjuent cause of death. In laryngo- 
fissure, one of the simplest external laryngeal operations, the death rate 
is about 4 per cent. In complete laryngectomy the mortality from 
pneumonia alone is much greater. 

3. Rectal Alimentation. — After complete laryngectomy the patient 
should be sustained by rectal alimentation for three or four days, after 
which he may be given food by the mouth. In the simple operations the 
rectal feeding may be discontinued somewhat earlier, proportionate to 
the extent of the operation. Indeed, in simple laryngofissure it may be 
dispensed with altogether. 

4. The Voice. — After laryngeal operations the voice may be good, 
provided the cords are not greatly damaged in the removal of the 
growth or the larynx is not removed in its entirety. If the tumor arises 
from the cords, and has penetrated deeply into their substance, they are 
necessarily removed, and the voice is consequently weak and otherwise 
impaired. After laryngofissure for laryngeal cancer the voice is usually 
more or less impaired, while in benign growths it is usually very good. 
After hemilaryngectomy and partial laryngectomy, one cord remains, 
and gives a husky though useful voice. In complete laryngectomy, 
when the trachea is stitched to the skin, there is no voice except in rare 
cases, where the tissues around the tracheal opening are thrown into 
vibration. ^\lien the trachea is stitched to the pharyngeal wound there 
may be more or less voice, or what passes for it. This is obtained by the 
peculiar conformation of the parts after the healing process is complete. 
The larynx being removed, the base of the tongue drops backward and 
downward, approximating the posterior wall of the pharynx. The 
cavity below the base of the tongue forms an air chamber, which is 
utilized to force air through the constriction formed by the base of the 
tongue and the pharyngeal walls, thus throwing the tissues at this point 



MALIGNANT NEOPLASMS OF THE LARYNX 547 

into vibration. The union of the trachea to the pharyngeal wound is not 
often practised, as the tension is so great that the tissues tear apart, 
slough away, or undergo gangrenous degeneration. 

5. Recurrence. — ^Recurrence of the cancerous growth is common on 
account of failure to make an early diagnosis. Intrinsic growths are 
less malignant than the extrinsic, hence recurrence in this variety is not 
so common. 

It may be said, then, that recurrence of laryngeal cancer is largely 
dependent upon the following factors: 

(a) Intrinsic cancers of the larynx do not recur as frequently as the 
extrinsic. 

(6) Conversely, extrinsic cancers more often recur than the intrinsic. 

(c) Extralaryngeal cancers, involving the larynx, have a still greater 
tendency to recurrence. 

(d) An early diagnosis and operation by laryngofissure, in intrinsic 
cancer of the larynx, should give a death rate of only 10 per cent., 5 
of the 10 dying of pneumonia rather than of recurrence. 

(e) Complete laryngectomy in cancer of the larynx was, up to 1889, 
attended by a death rate of 44 per cent., but since antiseptic surgery and 
an improved technique have been attained, it is reduced to about 15 
per cent. \Mien I speak of a death rate of 15 per cent., I mean death 
within three years after the operation. Quite a number die within a 
few months from pneumonia, septicemia, gangrene, exliaustion, or other 
sequelse. In still others recurrence brings on a fatal issue. 



CHAPTER XXXI. 

FOREIGN BODIES IN THE LARYNX, TRACHEA, BRONCHI, AND 
ESOPHAGUS. 

Etiology. — The lodgement of foreign bodies in the air passages is 
most common in infants and young children, as they have an instinctive 
desire to test all substances with their mouths. Coughing, laughing, 
crying, and ineffectual attempts to swallow draw the foreign body into the 
lower air tract. The smaller caliber of the larynx and air tubes in 
infants and young children renders the liability to the lodgement of 
foreign bodies greater. The smaller size of the lar^^lx and air tubes in 
infants and young children renders the obstruction greater than in older 
subjects from the same foreign bodies, hence the danger is often corre- 
spondingly greater in young subjects. 

The nature of the foreign bodies ranges anywhere from particles of 
food to marbles, coins, safety pins, burrs, and false teeth. 

Sjnnptoms. — ^The symptoms of a foreign body in the respiratory 
passages are those of obstructed breathing, laryngeal, tracheal, bronchial, 
or pulmonary irritation, and inflammation. The patient is suddenly 
seized with a violent choking and suffocative attack, characterized by 
cyanosis, aphonia, beads of perspiration on the forehead, and a weak 
pulse. These symptoms usually subside within a few minutes, to return 
again in a few hours or days. After the foreign body remains in the 
larynx for several weeks the spasmodic symptoms cease and the cough, 
etc., become more constant, often leading to a diagnosis of tuberculosis. 
A negative finding upon examination of the sputum clears the suspicion 
as to tuberculosis A positive finding does not, however, exclude a 
foreign body. A liistory of spasmodic cough and dyspnea and hoarse- 
ness followed by a persistent cough should excite suspicion of a foreign 
body in the respiratory tract if the patient is a small child. If the 
foreign body lodges in the ventricle of the larynx or in the subglottic 
space, hoarseness or aphonia is usually present. When the foreign 
substance changes its position, or an accumulated irritation arises, new 
suffocative attacks are excited. If the foreign body lodges in the trachea, 
bronchus, or one of the bronchioles, the voice remains clear. Bronchial 
rales or pneumonia may subsequently develop. In some instances the 
movements of the foreign body when in the bronchus may be detected 
by auscultation (Halstead). Dyspnea, attended by an elevation of 
temperature, often leads to an erroneous diagnosis of tracheal diphtheria. 
A laryiigoscopic examination may not reveal the foreign body, even 
though it lodged in the ventricle of the larynx. By direct laryngoscopy 
(Fig. 324), a better view of the larynx may be obtained. To Gustav 



FOREIGN BODIES IN THE LARYNX 549 

Killian belongs the credit of devising an apparatus whereby ahnost all 
of the respiratory tract may be clearly inspected for foreign bodies. 

Indications. — The indications are to remove the foreign body as 
soon as possible, as it may become dislodged and migrate to a new and 
more dangerous location. The continued presence of the foreign body 
may also give rise to considerable local irritation and subsequent edema 
or septic inflammation. Pneumonia is a rather frequent complication. 
In prolonged cases serious septic absorption may occur. Cases are re- 
corded w^herein the foreign body remained in the air passages for years 
without causing death. It should not be deduced from this fact that 
the early removal of the foreign body is not desirable. The risks attend- 
ing its continued presence in the air passages are infinitely greater than 
those incident to its early removal. 

The indications are, therefore, to institute proceedings for its removal, 
either by (a) holding the child's head downward and thumping it on the 
back (a dangerous procedure), the surgeon being prepared to perform 
a tracheotomy should suffocative symptoms supervene; (h) the titilla- 
tion of the larynx with the finger, in the hope of dislodging the foreign 
body or of exciting a coughing spasm, during which it may be expelled 
(a dangerous procedure) ; (c) the direct removal with instruments by the 
aid of a laryngoscopic mirror; (d) tracheotomy to relieve the suffocative 
dyspnea; if cyanosis is marked, tracheotomy may also be done to estab- 
lish a new avenue of inspection and to establish a new avenue for the 
instrumental removal of the foreign body; (e) and, finally, the indications 
are to use the Rontgen rays. If the foreign body is metallic or a bony 
substance, its location is easily shown, whereas if of vegetable matter it 
is less easily shown on a skiagraphic plate. 

Having located the foreign body, practice bronchoscopy or tracheos- 
copy and remove it with suitable instruments, by either upper or lower 
bronchoscopy, upper bronchoscopy being preferable when practicable. 

Treatment.- — It is generally understood among the laity that pound- 
ing a child on the back, especially when held head downward, will often 
dislodge a foreign body from the respiratory tract. These procedures 
have, therefore, usually been performed before a physician is called, 
provided it is known that a foreign body has been inhaled. Even though 
the foreign body is not thus removed, the suffocative symptoms often sub- 
side within a few minutes and the incident is often forgotten. When the 
symptoms recur a few hours or days later, without the marked strangu- 
lation and coughing seizures characterizing the initial attack, the family 
often sees no connection between this attack, and fails to report the 
occurrence of the first one to the attending physician. If the foreign 
body assumes a new location, the violent spasmodic seizures are repeated. 

If sutt'ocation is imminent, tracheotomy should be performed at once, 
for, as Chevalier Jackson says, if this is not done the child may never 
breathe again. \Mien this is done the breathing is immediately relieved, 
provided the foreign body is in the larynx. If it is in the trachea or 
l)r()nchus, it may not relieve the distress unless the foreign jjody is expelled 
tlii'oiigli (lie (niclical wound. As a nia((('r of fact, it is fre(|iu'nlly tlins 



550 DISEASES OF THE LARYXX 

expelled the moment the edges of the severed tracheal rings are retracted. 
If it is not voluntarily expelled, the lining mucous membrane of the tra- 
chea should he titillated, a procedure that sometimes causes its expulsion. 
Having performed tracheotomy, which is not attended bv voluntary ex- 
pulsion of the foreign body, proceed to pass a prolje upward through the 
tracheal wound into the larynx, to locate it if it is there. If lodged in 
the ventricular pouch or in the subglottic space, its location is not difficult. 
Having located it, introduce slender forceps, seize it, and remove it 
through the tracheal wound. 

If the foreign body is lodged in the trachea at its l)ifurcation, it may be 
easily seen through a tracheoscopic tube introduced through the trache- 
otomy wound (Plate IX). For illumination a Kierstein head lamp 
(Fig. 317) or a small electric lamp at the distal end of the tul^e, as 




Kierstein's lamji. 

devised by Jackson (Fig. 318), may be used. If a Killian or Jackson 
tube is not available, the foreign body may l)e detected with a probe 
introduced through the wound, after which slender forceps may be 
introduced through the wound without a tracheoscope for its removal. 
This method is inexact and crude, and should only be used as an 
emergency measure. 

If the foreign body is in one of the bronchi, its removal is more difficult. 
Indeed, if it is not voluntarily expelled upon making the tracheal opening, 
or upon titillating the tracheal mucosa, a bronchoscope should l)e intro- 
duced through the mouth. 

I am greatly indebted to Dr. Chevalier Jackson for personal instruc- 
tion and for the description of the technique of tracheobronchoscopy 
given in his classical treatise upon this subject. In descril)ing the 
technicjue of the various procedures for the removal of foreign liodies 
from the upper respiratory tract, I have adhered to his methods and 
largely to the instruments devised by him. In so doing I am not un- 
mindful of the fact that the greatest credit is due to Prof. Gustav Killian, 



PLATE IX 




Lower Bronchoscopy, a, the electric wire supplying the lamp 
at the distal end of the bronchoscopic tube; b, the conduit for 
aspirating the secretions and blood from the distal end of the 
tube; r, the tracheotomy wound; d, the distal end of the tube • 
e, the larynx;/, the foreign body; II, the lungs. ' 



FOREIGN BODIES IN THE LARYNX 



551 



of Freiburg, who was the first to remove a foreign body from the bronchus 
by upper bronchoscopy, and who has, through his writings and demon- 
strations, made bronchoscopy available to every specialist throughout 
the world. Jackson's illuminated bronchoscopic tubes are, however, 
easier for the inexperienced surgeon to use, and for this reason I recom- 
mend them in this work. 

Much credit is also due to Dr. Ingals, one of the first Americans 
to adopt bronchoscopy, for his writings, wherein he reports thirteen 
foreign bodies searched for or removed by bronchoscopy. Two deaths 
have followed the removal of the foreign body in his practice, the cause 
of death being attributed to reflex irritation of the vagus nerve. 




Jackson's split-tube spatulti for direet laiyiig(wcopy. 
greatly aids in overcoming the resistance of the muscles at the 
epiglottis and tongue are lifted forward. 



die B gives great leverage and 
of the tongue when the 



Tracheoscopy and Bronchoscopy. — The Preparation of the Patient. — If a 
general anesthetic, preferably ether, is used, the patient should be 
prepared as for a surgical operation. The morning hour before the 
patient has had breakfast is therefore the most favorable time, though 
in many cases the imminent danger in which the patient is placed leaves 
no choice in this respect. If time permits, the bowels should be emptied. 
If the tracheobronchoscope is to be used through a tracheal wound, the 
neck should be shaved and scrubbed. This route, as suggested by 
Jackson, is more septic than the other, as the instruments may be intro- 
duced through a sterile wound; whereas if they are passed througli the 
mouth, the danger of septic infection of the deeper air passages is more 
liable to occur. In spite of this fact, ii))|)('r l)r()ncli()scopy sliould be 
practised when feasible. 

The Anesthetic. — Stolid adiihs tolerate the iiitrodiictiou of the tubes 
under cocaine anesthesia, whereas more excitable ones, and children, 
ref|iiire n gonoral anesthetic. The larynx, tr;iche;i, and I'ight bronchus 



552 



DISEASES OF THE LARYXX 



may l^e cocainized by cotton-wound applicators before the introduction 
of the tubes, whereas the left bronchus and secondary and tertiary 
broncheoles can only be reached after the tube is introduced (Jackson). 
Ether is the best anesthetic. Ethyl chloride and chloroform should not 
be used, as they are not well tolerated by the lower respiratory tract. 
Profound anesthesia may be induced, though it is an advantage to retain 
enough of the reflexes for the patient to aid in disposing of the secretions, 
thus preventing the occurrence of pneumonia. 




The position of the patient and assistant in upper tracheobronchoscopy. (After Jackson.) 



Position of the Patient. — Killian usually passes the tubes under local 
anesthesia with the patient in the upright position. Jackson prefers 
general anesthesia, with the patient in the recumbent posture (Fig. 
319), as it is less tiresome for the operator to sit than to stand during 
what is often a prolonged ordeal. The head of the patient is also steadied 
more readily in this position. Jackson prefers the recumbent posture, 
also because the patient is in position for tracheotomy should suffocation 
occur during the attempted upper bronchoscopy. The head should 
hang over the end of the table, in Rose's position, and should be firmly 
grasped by an assistant, as shown in Fig. 319. The head should be 
slightly turned to one side, so as to bring the angle of the mouth parallel 



FOREIGN BODIES IN THE LARYNX 553 

with the trachea. The tube when introduced will then rest in the angle 
of the mouth. If the tube is to be introduced through the tracheal 
wound, the head should still be held in much the same position. 

Introduction of the Tube. — A tube should be selected of the proper 
length and size to reach the required depth and to correspond with the 
caliber of the respiratory tract to be explored. The length of the tube 
will depend somewhat upon whether it is to be introduced through the 
mouth or through the tracheal wound. The shorter the tube the clearer 
the field of inspection, though with Jackson's illuminated tubes the length 
of the tube makes but little difference. The size of the tube will depend 
upon the age of the patient and whether the trachea, bronchus, or one of 
the bronchioles is to be explored. The secondary and tertiary bronchi 
may only be explored with small tubes. Having selected a tube of the 
proper size and length, an assistant should cover it with sterile vaseline 




Battery for illuminating .Jackson's tubes. 

and hand it to the operator. The moment the tube is engaged in either 
the larynx or the tracheal wound the assistant should remove the 
obturator to allow free respiration. The tube should then be passed 
to the desired depth. Another assistant should have entire charge 
of the chloride of silver battery (Fig. 320) which furnishes the energy 
for the electric light at the distal end of the tube. He should now 
turn on the light while the operator inspects the field at the bottom 
of the tube. A third assistant should have sole charge of the ])um]) 
or suction apparatus (Fig. 321) with which the secretions are withdrawn 
from the tube, and should apply the suction at the suggestion of the 
operator. There is a suction tube in the wall bronchosco])e through 
which the secretions are removed. 'i'he use of a cottcm-wound 
applicator will often clear the field better Ihiiii the suclion apj)aratus. 
The fourth assistant should hold the palicul's licad in position. The 



554 



DISEASES OF THE LARYNX 



anestlietist should closely observe the pulse and respiration, as they are 
liable to stop through reflex irritation excited by the presence of the 
bronchoscope in the trachea. 




fur removing secretions in tracheobronchoscopy. 



Inspection. — ^The tumor or foreign body should be sought for at the 
depth of the tube by direct inspection through it. The illumination 
is brilliant, and a clear view may be obtained in most subjects if the 
secretions are removed by the pump and cotton-wound applicators. 




Long forceps for the 



,'al of foreign bodies by bronclioscopy, 



The Removal of a Foreign Body or Growth. — Long shanked hooks and 
forceps (Fig. 322) are introduced through the tube, the growth or foreign 
body seized and withdrawn. It often requires patience and perseverance 
to accomplish the purpose in hand. If the tube has been either carelessly 
or roughly introduced, the mucosa may be injured, the blood proving a 
worse obstacle to the view than the secretions. It is sometimes necessary 
to spend an hour or more in exploring the deeper air tract for a foreign 
body. Even then it may not be located. 



FOREIGN BODIES IN THE LARYNX 555 

Having completed the exploration successfully, the tracheotomy wound, 
if present, may be allowed to close at once, even though the obstruction 
to breathing is not completely relieved. The embarrassment still re- 
maining is usually due to the congestion of the respiratory tract in the 
region formerly occupied by the foreign body, and will disappear in 
from three to seven days. If the foreign body is not found, or, if found, 
is not removed, the tracheotomy tube may be left in place indefinitely, 
or until such time as the foreign body is found or is expelled voluntarily. 

Complications and Sequelae. — When tracheoscopy and bronchoscopy 
are performed through the mouth under a general anesthetic, pneumonia 
is occasionally a serious sequela. If performed through the mouth under 
partial general anesthesia, or under cocaine anesthesia, such a sequela 
does not so often occur. When performed through a tracheotomy 
wound under strict aseptic precautions, pneumonia rarely follows except 
as a result of a septic condition established by the presence of the foreign 
body. That is, bronchoscopy per se, when performed under good surgical 
conditions, does not often cause pneumonia. 

General Considerations. — According to Killian, foreign bodies lodging 
in the larynx, trachea, and bronchi may be divided into (1) hard and (2) 
soft varieties. He still further subdivides them for clinical purposes into 
(a) slender, (h) flat, (c) round, {d) cubical, (e) irregular, (/) metallic, {g) 
non-metallic Qi) friable, and {i) those liable to swell. These subdivisions 
are of clinical significance, because the size, shape, consistency, and 
chemical composition have much to d6 with the location and the technique 
of removing the foreign bodies. 

(a) Slender objects, as needles, pins, nails, spHnters, etc., usually 
lodge with the point turned upward, and they lie diagonally across the 
lumen of the tube. Needles and pins usually cause little inflammation, 
hence mucus and large granulations are not present to obstruct the 
view. Slender foreign bodies should be grasped with forceps (Fig. 322) 
near the point buried in the tube wall, pushed downward to disengage the 
buried point, and then removed through the bronchoscopic tube. Small 
nails may be removed with a rod-magnet introduced through the broncho- 
scopic tube. 

(h) Flat objects, as coins, buttons, pebbles (flat), usually lodge in the 
trachea, though small buttons may enter the bronchi. Coins are usually 
found in adults, as they are too large to enter the lower air tubes in infants 
and children. Children from three to sLx years old have a fascination 
for small flat pe})})les. They usually lodge in the trachea near the bifur- 
cation. Flat ol:)jects usually stand diagonally across the lumen of the 
trachea or bronchus, and are easily grasped with forceps. They may be 
removed by upper bronchoscopy in nearly all cases. 

(c) Kound objects, as glass beads, cherry stones, cofl'ee beans, etc., are 
frerjuently coughed uj) before assistance is called. They remain movable 
for {|uite a while, changing position from time to time. As Killian says, 
they are difficult to grasp with the forceps on account of their shape and 
the ease with which they elude the forceps, as it pushes the foreign body 
before it. A bead or other round object is, therefore, more easily 



556 DISEASES OF THE LARYXX 

removed if it is first pushed down to the hifurcation of the trachea, where 
it may he grasped with the forceps. Oval seeds, as prune stones, are 
rough and are easily grasped with the forceps. AMien present in children, 
prune stones are usually near the bifurcation of the trachea, as they are 
too large to enter the bronchi. 

(d) Cubical foreign bodies are difficult to grasp with forceps on account 
of their width. Killian recommends the use of his hook or hook forceps 
for this purpose. He also recommends lower bronchoscopy (through a 
tracheotomy wound) after failure by upper bronchoscopy. 

(e) Irregular objects, as bone fragments, are usually found in adults. 
^^^len present in children they lodge in the trachea. If small, the frag- 
ments may enter the right bronchus. As the bone fragment is usually 
rendered sterile by cooking, the infection attending its presence is some- 
what delayed. If allowed to remain in the bronchus or trachea too long, 
bronchitis, bronchiectasis, pulmonary abscess, or gangrene may develop. 
The bone fragments are irregularly fiat, and vary in size from 14 to 16 mm. 
long by S to 9 mm. wide. 

Carious teeth are occasionally aspirated into the trachea or bronchi, 
and when present quickly excite infective reaction. They should, there- 
fore, be removed as quickly as possible. 

Collar buttons are difficult to remove, especially when the larger flat 
end is turned upward. When the button lies crosswise of the air tube 
it may be grasped by its neck with forceps or a hook and removed. 

False teeth are usually too large to pass below the vocal cords, though 
Wild reports a case in which a plate wdth two false teeth entered the 
left bronchus. It was removed eleven days after the accident by lower 
bronchoscopy, after being observed by upper bronchoscopy. 

(/) Metallic substances may be clearly demonstrated by skiagraphy, 
whereas (g) non-metallic substances are less clearly defined. The skia- 
graph may, therefore, be used to locate the foreign body in many subjects. 

(h) Friable substances, as a fragment of an apple or a swollen and 
partially disintegrated bean, are difficult to remove, as they break into 
smaller fragments when seized with forceps. When thus broken the 
smaller particles are often coughed up, though it is somewhat dangerous 
to depend upon this mode of ejection, as the particles may be aspirated 
into one of the secondary or tertiary divisions of the bronchus. Should 
this accident occur, one lobe of the lung may be deprived of air and 
rapidly undergo retrograde changes, and become the seat of infection and 
inflammation. Furthermore, the foreign body is less accessible and 
more difficult to remove when in one of the smaller bronchi. Killian 
has constructed a forceps, modelled somewhat after an obstetric forceps, 
with which friable substances, as a swollen bean, fragments of apple, etc., 
may be grasped and removed without leaving fragments in the air tube. 

Barbed cereal spikes of wheat, rye, etc., are often difficult to remove, 
as the barbs usually point upward and engage in the mucous membrane 
when attempts are made to remove them. They have a tendency to grad- 
ually descend to the deeper tubes. A forceps that will grasp the entire 
length of the spike should l)e used, to prevent fragmentation of the spike. 



FOREIGN BODIES IN THE LARYNX 557 

(i) A swollen bean, or other substance liable to swell from the ab- 
sorption of the moisture of the lower respiratory tract, may gradually 
close the lumen of the bronchial tube (secondary) and thus shut off the 
air supply to a portion of the lung. The secretions are retained and 
undergo decomposition, and finally cause serious inflammatory reaction, 
as violent fever, pneumonia, and atelectasis. According to Killian, 39 
per cent, of these cases have died. 

Kilhan has collected 164 reported cases of foreign bodies in the lower 
respiratory tract which were treated by bronchoscopy. Of these, 8 
coughed the foreign body up. The result is unknown in 5, leaving 159 
cases in which the results are known. 

Twenty-one (13 per cent.) died, 2 from cocaine poisoning, 2 from 
stenosis, 16 from pulmonary complications, 5 with the foreign body m 
situ, and 11 in spite of removal. 

Upper bronchoscopy was fully successful in 54 cases. 

Lower bronchoscopy was fully successful in 63 cases. 

Of the 18 cases occurring in Prof. Kilhan 's practice, one died six 
months after the removal of the foreign body from severe pulmonary 
complications. 

In two he failed to find the foreign body. 

Upper bronchoscopy was performed in 12 cases. 

Upper and lower bronchoscopy in 5 cases. 

Lower bronchoscopy in 1 case. 

Direct Laryngoscopy. — Direct laryngoscopy should be done as a routine 
procedure in the examination of the larynx, as by it a better view of the 
parts is obtained. It may be done in the office under cocaine anesthesia, 
though it is a very disagreeable procedure. Foreign bodies and neo- 
plasms may also be removed by direct laryngoscopy; indeed, this should 
be the method of choice, especially in papilloma of the larynx, as 
repeated operations are often necessary to eradicate the disease. 

Anesthesia. — Cocaine anesthesia is usually sufficient for office examina- 
tions and for the removal of growths and foreign bodies from the supra- 
glottic portion of the larynx. First brush the larynx with a 4 per cent, 
solution of cocaine to lessen the reflex irritability, and after waiting 
a minute swab the larynx with a 20 per cent, solution of cocaine, under 
the guidance of a laryngeal mirror. One to three such applications at 
intervals of from three to five minutes generally induce local anesthesia 
profound enough to permit of an operation. Cocaine is not well toler- 
ated by children, and should be used with caution. 

Posture nf the Patient. — The sitting posture is generally used. The 
patient should l)e seated upon a stool 8 inches high; an assistant, sitting 
behind the patient, should hold his head retracted backward to bring 
the mouth in line with the axis of the trachea. The assistant should also 
steady the mouth gag in the patient's mouth and retract the u])]ier lip 
with the index finger to prevent its being injured between the iippci- tcclh 
and the tube spatula (Figs. 323 and 324)". The surgeon should slaiid 
in front of and over the patient, with liis eye in line with (he (uhe 
spatula and the larynx (Fig. 323). 



558 



DISEASES OF THE LARYXX 



Inirodnciion of ihc Tube Spatula.- — Pass the instrinnent into the throat 
until the (h'stal eiul of the instrument is l^ehind the tip of the epiglottis. 
Then draw the epiglottis forward against the base of the tongue, as shown 
in Fig. 324. If the spatula is placed too low, against the cricoid ring, 
the patient has a pronounced sense of suffocation; whereas if the instru- 
ment is withdrawn a little higher the dyspnea disappears and the patient 
breathes with a " })rassy" tubular sound. 

Examinaiion through the Tube Spatula. — Forcibly draw the epiglottis 
forward against the base of the tongue to bring the anterior portion of 
the larynx into view. This is very difficult to do in some patients and 
comparatively easy in others. If an illuminated instrument is used, the 
light should be turned on before introducing it into the mouth. If a 
non-illuminated tube is used, a Kierstein head lamp (Fig. 317) should be 
utilized to illuminate the lar\aix. 



t 



2 




The non-illuminated separable tube spatula. 

Upper Tracheobronchoscopy. — Upper tracheobronchoscopy is used for 
diagnostic and therapeutic purposes. By it the condition of the trachea, 
bronchi, and bronchioles may be observed, and treated by cotton-wound 
applicators moistened with the medicine. Jackson has observed and 
successfully treated ulcers of the trachea by upper tracheobronchoscopy. 
Persistent cough that resisted all other methods of treatment rapidly 
disappeared wlien the diseased tracheal mucous membrane was brushed 
with a mild solution of the nitrate of silver via the tracheobronchoscope. 
Foreign l)odies in the trachea, bnmchus, or one of the smaller bronchioles 
may be diagnosticated and removed through the tracheobronchoscope. 

Preparation of the Patient. — If a general anesthetic is to be given, the 
j)atient should be prepared as for a major surgical operation if time 
permits. 



FOREIGN BODIES IN THE LARYNX 



559 



Anesthesia. — A general anesthetic, preferably ether, should be admin- 
istered. The larynx, trachea, and bronchi should also be brushed with 
a 20 per cent, solution of cocaine. The larynx may be brushed with 
cocaine before the introduction of the bronchoscope, and the trachea 
and bronchi as the tube is passed downward. The anesthetic should 
not be carried to its full effect, as it is safer to preserve the reflexes, 
so that the patient will aid in disposing of the secretions. Otherwise, 




Direct laryngoscopy with Jackson's self-illiuninated tube spatula, a, electric cord supplying the 
lamp at the distal end of the spatula; b, the conduit for the electric cord; c, the tip of the tube 
spatula liolding the epiglottis forward against the base of the tongue; d, the conduit for the 
removal of the secretions and blood from the larynx during examinations and operations by direct 
laryngoscopy. 

aspiration pneinnonia may result. The use of cocaine in the larynx and 
trachea prevents the reflex phenomena due to irritation of the vagus 
nerve. After the bronchoscope is introduced the anesthetic should be 
given through the tul)e or by rectum after Cunningham's mediod. 

The Position of the Patient's Head. — After fixing the mouth open with 
a Furguson or Furguson-Pynchon mouth gag, have an assistant seated 
on a stool at the right side of the head of tlie patient, with his left foot on 
a low stool. The patient's head and neck are drawn beyond the end of 



560 



DISEASES OF THE LARYXX 



the table, and are supported and controlled by the assistant. His right 
arm is passed beneath the neck of the patient, the hand grasping the 
mouth gag and side of the face. The assistants left arm rests upon his 
left knee, and his hand supports the patient's head. The head and neck 
are thus under the complete control of the assistant (Fig. 319). By 
raising his right arm the neck is raised, and by raising the left hand the 
head is raised, and by reversing the movements of the arm and hand the 
opposite effects are produced. With the right and left hands the head 
may be rotated on its vertebral axis. The foot of the table should be 
fifteen inches lower than the head. 

Introducing the Split-tube Spatula. — The split-tube spatula should 
be introduced to expose the chink of the glottis while the tracheobron- 
choscope (Fig. 325) is being introduced. This procedure is identical 
with that described in the section on Direct Laryngoscopy, the on\y 
difference being the recumbent posture of the patient and the use of the 
split-tube spatula, Jackson's split-tube spatula (Fig. 318) is so con- 
structed that it may l)e easily removed after the tracheobronchoscope 
has entered the trachea. 



Fig. 325 

3r~ 



Jackson's self-illuminated tracheobronchoscope. 



Introducing the Tracheobronchoscope. — Having properly introduced 
the split-tube spatula and exposed the cords of the lar^iix to view through 
it, the tracheobronchoscope is introduced through the tube spatula to 
the larynx. The hght is turned on by an assistant, and the operator's 
eye is placed at the proximal end of the tracheobronchoscope to watch 
the respiratory movements of the vocal cords. The tracheobroncho- 
scope should i)e passed through the glottis during an inspiratory move- 
ment of the vocal cords, as they are separated at this time. 

Having passed the vocal cords and a short distance into the trachea, 
the split-tube spatula should be separated and removed from the mouth. 

The tracheobronchoscope resting in the angle of the mouth and trachea 
should be pushed downward (cocaine being applied to the mucous mem- 
brane with a long cotton-wound probe) until it reaches the foreign body, 
morbid process, or the bifurcation of the trachea. The tracheobroncho- 



FOREIGN BODIES IN THE LARYNX 561 

scope should rest in the left angle of the mouth if the right bronchus is 
to be entered; if the left bronchus, the right angle of the mouth. The 
assistant should constantly guard the upper lip of the patient with his 
index finger to prevent it being pinched between the upper teeth and the 
bronchoscope. 



t 



■-flftf^ 



i^^ 



Jackson's safety-pin closer. 

Having entered the right or left bronchus, the tube is passed down- 
ward, the operator watching for the secondary bronchi, morbid lesion, or 
the foreign body. By using the smallest-sized bronchoscope the terminal 
bronchioles may be explored for abscess or other morbid lesion, and if 
the diseased area is not accessible to bronchoscopic treatment it may be 
accurately diagnosticated and located and operated through the chest 
wall by a general surgeon. 

Fig. 327 



Mosher's safety-pin holder. 

The Removal of the Secretions and Blood. — ^The secretions and blood 
may be removed with Jackson's pump or aspirator (Fig. 321), wliicli is 
attached to the conduit for this purpose. An assistant should have 
entire charge of the aspirator, and use it as directed by the oj)erat()r. 
Long cotton-wound applicators may also l)e used to remove the secretions. 
According to Ingals, the preliminary use of atropine prevents excessive 
secretions. It also guards against reflex shock. 

The Removal of Foreir/n Bodies. — Variously shaped forceps, hooks, 
screws, etc., are used to remove foreign bothcs (Figs. 326, 327, 328 
and 329). 
36 



562 DISEASES OF THE LARYXX 

Topical Applications. — Ulcers and otlier local mor])id lesions of the 
mucous membrane of the trachea and bronchi may be brushed with a 
weak solution of the nitrate of silver through the tracheobronchoscope. 

Remarks. — The trachea and bronchi are elastic and expansile, and 
tolerate the straightening and dilatation with the bronchoscope. 

The illuminated tubes should not be boiled unless the electric light 
is removed. They should be immersed in alcohol. Likewise the 
unilluminated tubes should not be })oiled, as the lustre of the interior 
of the tul)e is thus destroyed and its capacity to carry the reflected 
rays from the head lamp is diminished. 

Do not use instruments in lower bronchoscopy that have just been 
used in upper bronchoscopy. Have freshly sterilized instruments ready 
for the purpose. Have sterile lamps in a sterile tube ready for use 
should a lamp burn out. 

The patient's head and face should l)e prepared as for a major opera- 
tion al)out the head. The teeth and mouth should be scrul)bed w^ith 
soap and alcohol. The operator and assistants should be dressed in 
sterile gowns and caps, a precaution especially necessary in handling the 
long instruments. 

The patient should be allowed to sit up as soon as possible, to prevent 
the occurrence of pneumonia. 



^*^*^ 




Jackson's forceps, curved jaws. Jackson's forceps, cupped jaws. 

Lower Tracheobronchoscopy. — Lower tracheobronchoscopy consists in 
introducing the tracheobronchoscope through a tracheotomy wound, as 
shown in Plate IX. 

Indications. — Lower tracheobronchoscopy is indicated when direct 
laryngoscopy or upper tracheoljronchoscopy fails. A larger tube may 
be used in lower bronchoscopy, an advantage in removing large foreign 
bodies. 

Position of the Patient. — Primary lower bronchoscopy should always 
be done in the dorsal position, as tracheotomy is to be performed. The 
patient should be placed in Rose's position, with the head extended 
beyond the end of the table. 

Low Tracheotomy. — Low tracheotomy should be performed, as the chin 
is thus farther removed from the operative field and is not so much in the 
way of the long instruments. The tracheobronchoscope may, however, 
be introduced through a high tracheotomy wound. 

Stop all bleeding before introducing the tracheobronchoscope. 

The trachea should l)e swabbed with a 20 per cent, solution of cocaine 
through Trousseau's dilator (Fig. 330). 

If the right bronchus is to be entered, have the patient's head turned to 
the left, and vice versa. 



FOREIGN BODIES IN THE LARYNX 



563 



Introduction of the Tracheohronchosco'pe. — Jackson's illuminated short 
tracheobronchoscope should be introduced through the tracheotomy 
wound, the operator's eye being at the proximal end of the tube 
watching for the bifurcation of the trachea (Plate IX). The end of the 
bronchoscope usually lodges against the bifurcation, so that both bronchi 




Trosseau's dilator. 

are visible. Lateral pressure in either direction will allow the tube to 
pass into one of the bronchi. The moment the tube enters the bronchus 
cough is excited. A cotton-wound applicator moistened with a 10 per 
cent, solution of cocaine should be applied through the tube and the tube 
passed to the secondary bifurcation (Fig. 331 SL). When a secondary 
bronchus is entered cough is again excited, and cocaine should be applied 




Traclieobroncl 



^ft main hioiiehus; SL, suijerior lobe bi'onclius; ML, middle 
,; IL, iiitViidi- lobe bruiR'hus. (Jacksf.n.) 



as before. It is iiii])()ssible U) maintain anesthesia deep enough to 
entirely abolish the cough reflex for any length of time, unless rectal 
anesthesia is used, and even then it is not advisa])le to abolish all the 
reflexes, as tht patient is thereby subjected to the danger of aspiration 
pneumonia. 



564 DISEASES OF THE LARYNX 

Having introduced the tracheobronchoscope, the foreign body and 
morbid lesions should be studied, treated, or removed. 

Ajtcr-treatmcnt. — The tracheotomy wound should not be sutured 
except at its upper and lower angles. The tracheotomy tube should be 
worn for a few days, but should be abandoned before the patient leaves 
the hospital. The tracheotomy wound should be cleansed every three 
hours with a warm 1 to 5000 bichloride solution. The wound should 
heal from the bottom, beginning with the severed tracheal rings. If 
the fleshy portion of the wound tends to heal first, it should be prevented. 



ESOPHAGOSCOPY; FOREIGN BODIES IN AND STRICTURES OF 
THE ESOPHAGUS. 

The examination of the esophagus through the mouth is now an 
established procedure, and should be considered in connection with 
bronchoscopy, as foreign bodies may lodge in either tube. The differen- 
tial diagnosis between a foreign body in the trachea or bronchi and the 
esophagus must, therefore, be made. Not only this, but the foreign body 
should be removed, whether it is in the bronchi, the trachea, or the 
esophagus. A brief description of esophagoscopy will, therefore, be 
given in this work. 

The sizes of tubes required, according to Chevalier Jackson, are, for 
infants, 7 mm., and for adults 10 mm. in diameter. 

The normal appearance of the esophageal lumen with the Jackson 
self-illuminated tubes is a whitish grayish pink, in stong contrast to the 
red color of the tracheal membrane. 

Examination of the Upper End of the Esophagus. — ^This is the 
easiest of all the examinations with the straight tubes, and is accom- 
plished by the same technique described under Direct Laryngoscopy 
(p. 359). According to Jackson, the split tubular speculum (Fig. 318) 
should be passed back of the base of the tongue until the epiglottis 
appears, after having cocainized the iniroitus esophagi with a 10 per 
cent, solution. Having engaged the tip of the epiglottis, a straight 
cotton-wound applicator, dipped with a 10 per cent, solution of cocaine, 
should be passed through the tubular speculinn and applied to the 
epiglottis, the laryngeal and the esophageal orifices, waiting a few 
minutes for anesthesia to supervene. The tubular speculum is then 
passed down back of the epiglottis and the cricoid cartilage, and 
lifted forward against the base of the tongue. The larynx and the 
esojjliageal depression are thus brought into view. The spatular end of 
the tubular speculum is inserted into the esophageal depression to a point 
below the arytenoid cartilages, and far enough to engage the posterior 
portion of the cricoid cartilage. The cartilage should then be lifted 
forward, thus exposing the pyriform fossre and the esophageal lumen. 



ESOPHAGOSCOPY 565 



ESOPHAGOSCOPY. 

Dr. Chevalier Jackson gives the following description : 

"Preliminary to passing a tube into the lumen of the esophagus the 
upper end of the esophagus should be examined, as described in the 
preceding section, to learn the pathological conditions present in this 
region. This procedure will prevent the making of a false passage 
through an ulcerated surface and will locate a foreign body if present at 
the entrance of the esophagus. In passing the long tube extreme gentle- 
ness should be practised. If the tube does not readily pass, it is either 
not correctly placed or it is improperly directed. The tube should be 
lubricated with sterile vaseline. The proximal end should be held 
lightly with the right hand, the handle directed horizontally to the right, 
The forefinger of the left hand is passed into the right glosso-epiglottic 
fossa, posteriorly to the lateral glosso-epiglottic fold and posteriorly to the 
tense pharyngo -epiglottic fold, and, if possible, into the right pyriform 
sinus. 

"The tube should then be made to follow the same route, while the 
finger slides toward the median line and lifts the tongue and anterior 
pharyngeal tissues upward (dorsal decubitus). When the cricoid 
cartilage can be reached, which is possible only in children, it is better to 
lift upon it directly rather than upon the soft tissues. When possible, 
as it usually is in adults, the cartilage should be lifted indirectly by 
traction upon the tissues at the extreme point reachable with the finger, 
often the right glosso-epiglottic fossa." 

The head of the patient should be held in extreme extension with the 
mouth widely open, as shown in Fig. 319. 

"After the introitus is passed the obturator is removed, and the cord 
is attached to the light carrier by the bayonet fitting. The tube must be 
guided by the eye so as to follow the esophageal lumen by sight. After 
passing the introitus the head of the patient should be raised slightly 
to prevent the tube pressing on the trachea." 

The entire lumen of the esophagus may be examined for stricture 
or other pathological lesion , and for foreign bodies. When a foreign body 
is found it may be removed as by bronchoscopy. By using a longer tube 
almost the entire surface of the stomach may also be inspected with 
great clearness of illumination with Jackson's self-illuminated gastro- 
scope. 

In one of my cases the skiagrapher reported the foreign body, a penny, 
to be located at the bifurcation of the traceha. As it was impossible for 
me to get to the studio to examine the plate, I acted upon his diagnosis 
and attempted to locate the foreign body in the trachea. At one time I 
passed the tube into the esophagus and heard a slight metallic click. 
Further search failed to elicit the metallic sound. When I viewed the 
skiagraphic plate a few days later I found the shadow of the penny on a 
level with the cricoid cartilage, instead of at the bifurcation of the trachea, 
as reported by the skiagrapher. Nine days after the attempted removal 



566 



DISEASES OF THE LARYXX 



l)y bronchoscopy the penny was passed per rectum, thus showing the 
penny to have been in the upper portion of the esophagus, from where it 
probably was dislodged at the time I heard the metallic click. Another 
point of diagnostic interest in this case was the position of the penny. 
Its flat surface stood at right angles to the vocal cords, a fact which 
immediately attracted my attention when I saw the plate a few days later. 




Fig. 332. — The probable position assumed by a penny when lodged in the subglottic space. 
Fig. 333. — The position assumed by a penny, as shown by skiagraphy, when lodged in the 
mouth of the esophagus of a child, aged three years. (Author's case.) 



Had the penny been in the subglottic space, its edge probably would 
have presented anteriorly. The location and position of the penny led 
me to inform the parents that it was not in the trachea, but was in the 
upper part of the esophagus at the time the skiagraphic plate was made. 
This diagnosis was later verified by the passage of the penny (Figs. 
332 and 333). 



PART lY. 
THE EAR. 



CHAPTER XXXII. 

THE CLINICAL ANATOMY AND PHYSIOLOGY OF THE EAR. 

The organ of hearing is divisible into (a) the external ear, (b) the 
middle ear, and (c) the internal ear. 

THE EXTERNAL EAR. 

From a clinical point of view the auricle is of interest on account of the 
destructive inflammatory processes which attack its cartilaginous frame- 
work and the perichondrium covering it. Perichondritis and chondritis 
of the auricle occurring in the insane from traumatism has been fre- 
quently observed and reported (Fig. 348). Perichondritis following the 
mastoid operation occasionally occurs. I have seen but one case in my 
practice, and it developed several weeks after the mastoid operation, the 
exciting cause undoubtedly being the influenza bacillus as it followed an 
attack of la grippe. In performing the plastic operation upon the meatus, 
that is, in making the Koerner, Panse, Siebenmann, or the Ballance 
incisions, the cartilage of the auricle is included; hence it is necessary to 
exercise great care as to surgical cleanliness, otherwise infection of the 
perichondrium and cartilage may occur. 

The external auditory meatus is divisible into a cartilaginous and an 
osseous portion. The cartilaginous portion of the meatus (the auricular 
extension) is attached to the osseous or deeper portion by bands of 
fibrous tissue. The superior and posterior walls of the cartilaginous 
meatus are thinner than the anterior and inferior walls. The inferior 
wall extends deeper along the floor of the meatus than the other w^alls, 
and is known as the processus triangularis. The anterior wall of the 
cartilaginous meatus is crossed by two or three fissures, which are filled 
with connective tissue and a few muscle fibers. These fissures are 
called the fissures of Santorini, and they render the auricle more movable. 
They are of clinical importance, first, because they aft'ord an outlet for 
the discharge of pus into the meatus in deep abscess of the parotid gland, 
and secondly because they permit the auricle to be turned over on the 
cheek dun'iii:;; the mastoid operation. 



568 THE EAR 

In the newborn the meatus is fibrous throughout its entire length, 
and its walls are collapsed and in apposition. Bone salts are gradually 
deposited and the canal assumes its open condition. 

The sebaceous glands are limited to the cartilaginous portion of the 
meatus, hence furunculosis of the meatus is confined to this area. The 
beginner in otology is sometimes confused in making a differential diag- 
nosis between acute suppurative mastoiditis, with bulging of the post- 
superior wall, and furunuculosis of the cartilaginous meatus. In the 
first instance the bulging is in the bony meatus close to the drumhead, 
and the auricle is not tender or sensitive upon manipulation. In the 
second instance the bulging is more external in the cartilaginous meatus, 
and the auricle is extremely sensitive upon manipulation. The sensi- 
tiveness of the auricle in furunculosis is due to the fact that the inflam- 
matory reaction attending the furuncle or boil has extended by continuity 
of tissue from the cartilage of the meatus to the cartilage of the auricle, 
and thereby renders the nerve fibers of the auricle exquisitely sensitive. 



THE MIDDLE EAR. 

The drumhead or eardrum forms the outer wall of the middle ear. 
It is a composite membrane of three layers, the outer one being a reflection 
of the skin of the meatus, the middle one being fibrous tissue, and the 
inner a reflection of the mucous membrane of the middle ear. The 
handle of the malleus is embedded within these structures, hence the 
sound waves impinging upon the eardrum are transmitted to the handle 
of the malleus, and from thence to the incus and stapes where the foot 
plate transmits them to the sound perception apparatus. 

The membrana tympani is of clinical importance chiefly on account of 
the various changes in its appearance in diseased conditions of the middle 
ear. These changes are, therefore, of diagnostic value. In order to 
fully appreciate the abnormal appearances of the eardrum, it is first 
necessary to know the normal characteristics. A normal drumhead is 
characterized by the presence of the handle of the malleus, the short 
process of the malleus, the triangular cone of light, the anterior and 
posterior folds, and a faint view of the long process of the incus seen 
through the semitransparent eardrum. 

AYhen the Eustachian tube is closed the air within the middle ear 
cavity becomes rarefied by the gradual absorption of the oxygen into the 
l>lood of the surrounding tissues. As a result of the negative pressure 
thus brought about, the eardrum is pushed inward — that is, the eardrum 
is retracted. This changes the contour of the eardrum as viewed through 
the external auditory meatus. The cone of light is broken or altogether 
lost, the handle of the malleus is drawn inward and is foreshortened, 
the short process of the malleus projects more prominently toward the 
observer's eye, and the anterior and posterior folds which arise from the 
short process are accentuated. 

In retraction due to obstruction of the Eustachian tube the membrana 



THE EUSTACHIAN TUBE 569 

tympani is regular or uniform throughout its entire area, with the excep- 
tion of the part containing the malleus. If the retraction is due to an 
adhesion to the inner wall of the tympanic cavity the membrane is 
irregularly retracted. The membrana tympani, upon suction with 
Siegle's otoscope, remains fixed at the point of adhesion, and is distended 
in other areas, giving a blistered appearance. 



PERFORATION OF THE MEMBRANA TYMPANI. 

The clmical significance of perforation of the membrana tympani when 
due to middle-ear disease is somewhat dependent upon whether it is 
marginal or central in location. When marginal it usually signifies 
bone necrosis, and when central (away from the margin) it signifies a 
simple middle-ear suppuration without bone necrosis. 

Its significance is still further difi^erentiated by noting its exact location; 
that is, if it is marginal the bone necrosis is in the immediate vicinity of 
the marginal perforation. If, for instance, the perforation is in the margin 
of Shrapnell's membrane (membrana flaccida), immediately above the 
short process of the malleus, the attic wall is necrotic; if it is in the 
postsuperior margin of the eardrum (the part nearest to the antrum) 
the mastoid antrum is necrosed. 

The point to be borne in mind is that the perforation is secondary to 
the bone necrosis, the necrotic process extending from the ear cavities 
to the eardrum. Its clinical significance is, therefore, an index to a 
preexisting morbid process in the tympanic cavities, the focal point of 
which is in the neighborhood of the perforation. Leutert, Zaufal, and 
others have called attention to the significance of the foregoing facts. 

The further elaboration of the clinical significance of perforations of 
the eardrum is given in Fig. 377. 

THE EUSTACHIAN TUBE. 

The second and most common avenue of approach to the middle-ear 
cavity is through the Eustachian tube. It is through this channel that 
nearly all middle-ear diseases effect an entrance into the middle-ear cavity. 
The tube is about 36 mm. long, the pharyngeal opening being about 
25 mm. lower than the tympanic opening. The tympanic opening corre- 
sponds to the anterosuperior quadrant of the eardrum, hence it is not in 
the most dependent portion of the cavity. This does not interfere with 
drainage under normal conditions, as the cilise of the epithelium of the 
tympanic cavity sweep the secretions to the opening of the tube and on 
through it to its pharyngeal opening. If, however, the eilisc ore impaired 
in their functional activity by an inflammatory or other morbid process, 
the elevated position of the tympanic orifice of the tube materially inter- 
feres with the drainage. Under these conditions the secretions are 
retained, decomposition follows, and further irritation of the mucous 
membrane results. 



570 THE EAR 

The tympanic end of the tube has an osseous framework, and is about 
8 mm. long. The pliaryngeal end of the tube has a cartilaginous and 
membranous framework, and is about 15 mm. long. The tube is trumpet- 
shaped at l)oth extremities, and is narrowest at the junction of the osseous 
and cartilaginous portions. This is known as the isthmus. The frame- 
work is lined with mucous membrane which is covered with ciliated 
epithelium, which carries the secretions toward the pharyngeal orifice. 

Under ordinary conditions the membranous walls of the tube are in a 
state of collapse, and only open when certain palatal muscles are con- 
tracted. Yawning and swallowing cause these muscles to contract, and 
air is thus admitted into the tympanic cavity. 

llie muscles regulating the patency of the pharyngeal orifice of the 
tube are the tensor veli palati and the levator palati; they also elevate the 
soft palate and assist in approximating it against the posterior wall of 
the pharynx in the act of swallowing. As the superior ends of the muscles 
are attached to the cartilaginous lip and to the membranous portion of 
the tube, and the inferior end to the soft palate, it is obvious that the 
contraction of the muscles will produce a twofold result, namely, the 
pharyngeal orifice of the tube is opened and the soft palate is elevated. 

^Yhen, for any reason, the act of swallowing does not open the tube 
sufficiently to admit air into the tympanic cavity, the oxygen is absorbed 
from the contained air by the blood in the surrounding tissues, and a 
partial vacuum, or negative pressure, results. The blood in the siu'- 
rounding tissues is attached to the parts by the negative pressure, and 
congestion results. The retained secretions undergo decomposition 
and irritate the lining mucous membrane. The hyperemia induces 
overnutrition. As a result of the combined irritation and increased 
nutrition the mucous membrane becomes thickened, either by hyper- 
trophy or hyperplasia. The secretions are not only retained in excessive 
quantity but are changed in character. This condition is known as 
middle-ear and tubal catarrh. 

Anything that obstructs the flow of secretions of the Eustachian tube 
predisposes the mucous membrane of the tube and middle ear to infec- 
tion and inflammation. The two great underlying principles relating 
to the etiology of inflammation of mucous membrane-lined cavities are: 
(a) The exciting cause of inflammation is almost always a pathogenic 
microorganism. The microorganism is powerless to grow upon healthy 
tissue, hence the second great underlying principle relates to the con- 
ditions which favor infection. (6) The predisposing cause is usually 
an obstructive lesion interfering with the drainage and ventilation of 
the cavity, whereby the resistance of the tissues is lowered. When the 
resistance of the tissues is lowered the pathogenic microorganisms 
flourish, and with their toxins excite the reactions of inflammation. 

The action of the tensor and levator veli palati muscles is so intimately 
associated with that of the muscles of the palate and pharynx that it is 
somewhat difficult to estimate the influence of the other muscles on the 
patency of the tubes. The pharyngopalatinus (posterior pillar of the 
fauces) has its upper attachment in the soft palate, and it contracts 



THE TYMPANIC CAVITY 571 

during deglutition, and thus indirectly exerts a tensive action upon 
the tubal muscles. In inflammatory processes involving the tonsils and 
the faucial pillars the swollen condition of the palatopharyngeus 
muscle indirectly interferes with the action of the tubal muscles. In 
this way disease of the tonsil causes tubal and middle-ear disease; 
that is, drainage and ventilation are interfered with. Whatever may be 
the explanation, it is a common clinical observation to see tubal and 
middle-ear catarrh improved by the removal of the tonsils. 

The anterior wall of the tube is membranous, while the upper and 
posterior walls are cartilaginous. The tensor and levator veli palati 
muscles are attached to the membranous portion of the tube, hence 
when they contract the tube is opened to its isthmus. 

Much has been written concerning the normal patency of the Eusta- 
chian tube, and the preponderance of the evidence is in favor of the 
view that it is closed except during the act of deglutition. Politzer's 
experiment, consisting of a vibrating tuning fork held in front of the nose, 
shows that it is but faintly heard except during deglutition, thereby 
proving that the tube is closed under ordinary conditions and is open 
during deglutition. This permits of the interchange of air between the 
pharynx and the middle ear, and maintains an equilibrium of pressure 
on the inner and the outer surfaces of the membrana tympani. 

The pharyngeal end of the tubal cartilage (posterior and superior 
walls) forms a projecting lip or tubal prominence on the lateral wall of 
the epipharynx. Just behind this is a groove known as Rosenmiiller's 
fossa. The fossa and tubal prominence are the landmarks used in the 
introduction of the Eustachian catheter. The tip of the catheter is 
first lodged in the fossa of Rosenmiiller, then drawn forward, gliding 
downward and inward over the prominence, and thence upward and 
outward into the tubal orifice. 

To inflate the tube and middle ear, the compressed air should be ap- 
plied at the beginning of the act of deglutition, as the tubal muscles are 
then contracted and the tube open. The Eustachian tube of an infant 
is shorter, straighter, and more easily inflated than that of an adult. 
In an adult the tube is sharply bent at the isthmus, whereas in an infant 
the tube is nearly straight. A lower degree of air pressure should, there- 
fore, be used in tympanic inflation of infants than in adults. Earache 
in infants and young children is often quickly relieved by inflation, as it 
is due to tubal congestion. 



THE TYMPANIC CAVITY; TYMPANUM; CAVUM TYMPANI. 

The tympanic cavity is the air space between the tympanic orifice of 
the Eustachian tube and the mastoid antrum. Its lining mucous mem- 
brane is continuous with that of the Eustachian tube, and extends to the 
antrum and mastoid cells. It is covered with ciliated epithelium whose 
wave-like motion carries the secretion to the Eustachian tube. 

The upper wall (tegmen tympani) of the tympanic cavity is close 



572 THE EAR 

to the cranial cavity; the outer wall is the eardrum; the inner wall is 
contiguous to the labyrinth; its posterior wall to the mastoid cells, its 
anterior wall to the carotid artery and its lower wall to the jugular bulb. 
The facial nerve runs across the upper and posterior wall and is usually 
enclosed in a bony covering, though numerous instances are on record 
in which the bony covering was absent. 

The Contents of the Tympanic Cavity. — The tympanic cavity 
contains the chain of ossicles, the tympanic muscles, and the chorda 
tympani nerve. The handle of the malleus is attached to the membrana 
tympani, and the foot plate of the stapes is attached to the membrane 
of the oval window. The incus is suspended between the malleus and 
stapes, and completes the anatomical connection between the membrana 
tympani and the labyrinth. The chain of ossicles transmits the sound 
waves from the membrana tympani to the labyrinth, though there is little 
doubt that some waves are transmitted through the air in the tympanum 
to the round or oval window without the intervention of the ossicles. 
I recall one patient on whom I did a radical mastoid operation, removing 
the malleus and incus, who heard whispered speech at ten feet, showing 
that good hearing is possible without the ossicles. 

The Chain of Ossicles and the Membrane of the Oval Window. — It is 
shown by the case just cited that all the receiving apparatus may be 
removed except the contents of the oval window without greatly im- 
pairing the hearing. Orientation of hearing is greatly diminished, as is 
also the faculty of keying the perception apparatus to catch sounds more 
accurately. The tensor tympani and the stapedius muscles are rendered 
ineffective in the removal of the malleus and incus, hence the ear has 
lost its focusing apparatus. The membrana tympani receives a larger 
number of sound waves than the foot plate of the stapes, hence the hearing 
is more acute with the eardrum and the ossicles intact than it is with them 
absent. 

A Physiological Law. — It may be laid down as a physiological law 
that anything that interferes with the normal tensipn existing between 
the membrana tympani, ossicles, and the contents of the oval window will 
cause tinnitus and deafness. Hence pathological changes in the eardrum, 
thickening or other change in the mucous membrane covering of the 
ossicles, ankylosis of the ossicles, especially of the foot plate of the stapes, 
as in spongifying of the bony capsule of the labyrinth, etc., result in 
tinnitus and deafness. Catarrhal inflammation of the mucous membrane 
of the middle ear and Eustachian tube induces a negative pressure in 
the tympanic cavity, and disturbs the normal tension between the ear- 
drum and the oval window; the mucous membrane of the walls of the 
tympanic cavity and of the ossicles is thickened, and tinnitus and deaf- 
ness follow. The inflation of the tympanic cavity in tubal and middle- 
ear catarrh restores (in a degree) the normal tension and decreases the 
congestion of the mucous membrane, and thereby lessens the tinnitus 
and deafness. 

The heads of the malleus and incus and their ligamentous attach- 
ments to the walls of the tympanic cavity divide the cavity into two 



THE TYMPANIC CAVITY 573 

compartments, namely, the atrium, or middle ear proper, and the attic. 
When there is a suppurative process in the attic or the antrum and 
mastoid cells for a considerable time, adhesive bands form and still 
further increase the barrier between the atrium and the attic. The 
drainage of the secretions is blocked, and gives rise to retention and 
decomposition of the secretions and to pressure symptoms, as pain and 
tenderness. Necrosis is also augmented by the increased pressure from 
the retained secretions. Attic suppuration, and suppuration in the 
antrum and mastoid cells in old chronic cases, is, therefore, a more serious 
condition than suppuration with its focal centre in the atrium. 

The chorda tymparii nerve passes through the upper portion of the 
atrium between the handle of the malleus and the long process of the 
incus, and is usually severed or destroyed in the radical mastoid operation. 
As a consequence, the sense of taste at the base of the tongue and the 
neighboring parts of the fauces is impaired; indeed, it is perhaps best 
to destroy the nerve as the irritation during the application of post- 
operative dressings excites a disagreeable sense of taste. 

The Walls of the Tympanum.— The superior wall, the tegmen 
tympani, is a thin plate of bone forming a portion of the middle fossa 
of the skull, and it is frequently the seat of necrosis in suppurative in- 
flammation of the middle ear. The necrotic process often extends through 
it, and thus exposes the dura to the infective bacteria present. Ordinarily 
a wall of granulation tissue is formed in Nature's effort toward repair 
and protection. Such a perforation may, therefore, exist for years 
without involving the cranial contents. On the other hand, if the 
secretion is blocked by the ossicles, their ligaments, and the adhesive 
bands at the floor of the attic, the infective bacteria may be forced through 
the granulation tissue into the cranial cavity, and excite meningitis or 
brain abscess. 

One of the strongest arguments against curettage of the attic through 
the external auditory meatus is, that the granulation tissue may be 
removed and the dura exposed to the pathogenic bacteria. The same 
objection does not hold to its removal during the radical mastoid opera- 
tion, as in this case all morbid material is or should be removed and 
perfect drainage is established. 

The inferior wall or floor of the tympanic cavity is of clinical interest, 
on account of its proximity to the jugular bulb. It is only in exceptional 
cases, however, that the floor is thin, hence the jugular bulb is ordinarily 
in ]io danger in the curettage of the floor. Occasionally the floor is so 
thin that in curetting granulations from it there is danger of injuring 
the jugular bulb and causing serious or even fatal hemorrhage. Wlien 
the jugular bulb is thrombosed, necrosis of the floor of the tympanic 
cavity may occur, and granulations spring from this point. Granula- 
tions on the floor of the tympanum in cases of lateral siiuis thrombosis 
are significant of involvement of the jugular bull). 

The outer wall of the tympanum is chiefly composed of the niembrana 
tympani, though at its upper and lower portions it is composed of 
bone. The bony wall at its upper portion forms the outer wall of the 



574 THE EAR 

attic, or the recessiis cpitympanicus (Fig. 334). The handle of the 
malleus is embedded in the membrana tympani, as is also the short 
process, located at the upper extremity of the handle. 

The inner wall of the tympanum is of interest because it also 
forms the outer wall of the labyrinth, and because of the presence of 
inij)ortant structures concerned in the function of sound conduction (Fig. 
334). The most important of the structures concerned in sound con- 
duction are the oval window (fenestra vestibuli), the stapedius muscle, 
the tensor tympani muscle, and the round window (fenestra cochlea). 
The other important structures are the promontorium, a projection due 
to the beginning of the basil turn of the cochlea; the prominentia canalis 
facialis, which forms the upper and posterior border of the fossulafenestrse 
cochleae; and the prominentia canalis semicircularis lateralis. The 
prominences of the facial nerve canal and of the lateral semicircular 
canal form the median boundary of the attic (recessus cpitympanicus), 
and they lie in close relation to the deep portion of the postsuperior wall 
of the external auditory meatus. The removal of this wall in the radical 
mastoid operation is liable to result in injury to these two structures. 
The Stacke protector is sometimes used to protect these structures by 
passing it from the middle ear upward and backward into the epitympanic 
space. 

The facial nerve is usually covered by bony tissue, though in excep- 
tional cases it is not. In necrotic processes it is frequently exposed, 
hence extreme caution is necessary in removing the postsuperior wall 
of the meatus, lest the nerve be injured. The nerve comes sharply 
outward from the cranium and then turns downward, forming a rather 
sharp knee, without coming near the mastoid surface. Hence, the 
outer portion of the postsuperior wall of the meatus may be removed 
freely without danger of injuring the facial nerves. T. Passmore 
Berens reported a case in which the facial nerve came near the surface 
and in which it would have been injured if the posterior wall of the 
meatus had been removed as completely as usual. The posterior wall 
should therefore be removed in shavings, the operator constantly 
watching for the dense bone surrounding the nerve. The bone of the 
postsuperior wall of the meatus is often spoken of as a "wedge of 
bone," from the fact that wdien removed it is triangular in shape. 
The point of the wedge is at its deepest portion, while the pole is the 
external portion. The point of the wedge forms the outer wall of the 
aditus ad antrum, the constriction which marks the boundary between the 
attic and the antrum. In removing the postsuperior wall of the meatus 
(wedge of bone) it should be remembered that the outer or more super- 
ficial portion may l)e freely chiselled away, but that as the inner or deeper 
portion is approached, the upper and lower lines of incision should be 
gradually approximated. In this way the channel of communication 
(aditus ad antrum) between the antrum and the attic (epitympanic 
space) is enlarged. 

The malleus and incus are also removed in the radical mastoid opera- 
tion, and the obstruction to the drainage of the mastoid cells and the 



THE TYMPANIC CAVITY 575 

antrum is thus completely removed. The chief objection to the removal of 
the malleus and incus (ossiculectomy) for the cure of chronic suppura- 
tive ear disease is that neither is free drainage thereby established, nor is 
all the morbid material removed; that is, the necrosis and granulations 
are usually present in the antrum and cells as well as in the attic, hence 
the removal of the malleus and incus does not relieve the trouble except 
in the attic. Only the radical mastoid operation does this. If the dis- 
ease is limited, or focalized in the attic, ossiculectomy may be all that is 
necessary to do. (See Mastoid Operations.) 

The Antrum. — The antrum is embryologically a part of the middle 
ear, while the mastoid cells are not. It communicates with the attic 
through the aditus ad antrum. The mastoid cells drain into it. The 
ciliated epithelium lining the cells, antrum, tympanum, and the Eusta- 
chian tube propels the secretions successively through these parts to 
the pharyngeal orifice of the tube. In severe acute inflammation, and 
in pro onged chronic inflammation, the epithelium is denuded in certain 
areas of its cihse, and the drainage of the secretions is interfered with. 
The superficial destruction of tissue thus started may extend to the deeper 
tissues, as the epithelium, mucous membrane, periosteum, and the bone. 
Necrosis may be thus established. When such extensive destruction 
has become established there is little probability of a cure except by the 
radical or the Heath operation. 

The Mastoid and Temporal Bone Cells.— A knowledge of the possible 
distribution of the mastoid and temporal bone cells is sometimes a matter 
of extreme importance in the successful treatment of mastoiditis. In 
many chronic cases it is absolutely necessary for the surgeon to remove 
all morbid tissue, and to establish free drainage of the remotest air spaces 
in the temporal bone. The pneumatic cells are not always confined 
to the mastoid process, but may be in the posterior root of the zygoma, 
the squamous plate of the temporal, or even in front of the external 
auditory meatus. I have seen cases in which pus-discharging cells were in 
front of the meatus with a canal of communication leading to the antrum. 
Had they not been opened and exenterated in the course of the radical 
operation, the operation would have been a failure. Hence it is neces- 
sary in all chronic cases to make careful search for pneumatic cells in 
other regions than the mastoid process. In one of Dr. Wale's specimens 
the mastoid cells seemed to communicate with the sphenoid sinus. 

One object of the radical mastoid operation is to convert the middle 
ear, antrum, and mastoid (and other pneumatic cells of the temporal 
bone) into one irregular but freely opened cavity; another object is to 
remove all the morbid tissue from these and other areas of the temporal 
bone. If this is done, and the parts are kept in an aseptic condition 
during the healing process, a cure will follow. To neglect either of the 
three cardinal principles is to invite failure. I have heard the fallacious 
statement made that no operator can be sure that all cells are reached 
in the operation. An experienced and intelligent operator can deter- 
mine the extent of the disease in all cases by exercising care in the study 
of the bony tissue as it is exposed. He can open the root of the zygomatic 



576 THE EAR 

process above the antrum and the meatus, and if there are diseased cells 
there he can remove them; he can extend the operation from there to 
the squamous portion of the temporal bone, and to the region in front of 
the external auditory process. The cells in the mastoid bone are more 
easily exposed, and there is no excuse for overlooking any of them. 

When the petrous portion of the temporal bone is involved, the func- 
tional tests of hearing show a loss of hearing by bone conduction, or the 
hearing may be entirely lost on the affected side. Furthermore, an 
inspection of the promontorium of the inner wall of the middle ear may 
show an area of necrosis and granulation tissue, which should be thor- 
oughly scooped out with a curette. If this is done a cure will prob- 
ably follow, as the petrous portion of the bone is so dense there is little 
likelihood of the diseased process extending farther after thorough 
curottement. (See Surgery of the Labyrinth.) 

The Arteries of the Middle Ear. — The middle ear receives its 
chief blood supply from branches of the internal carotid. The branches 
pass backward through the canaliculus carototympanici to the mucous 
membrane of the middle portion of the tympanic cavity. The middle 
meningeal artery sends a branch to the upper portion of the middle ear, 
while the A. stylomastoidea sends a branch to the postinferior portion 
and to the mastoid cells. As all these branches are quite small, they 
bear no special clinical significance so far as hemorrhage during an 
operation is concerned. 

The External Landmarks of the Temporal Bone.— A study of the 
external contour and anatomical markings of the temporal bone in 
each individual case operated upon yields much valuable information 
concerning the deeper structures of the bone. The antrum can be fairly 
well located by observing the mastoid fossa with its numerous perfora- 
tions, which give it a sieve-like or wormeaten appearance (Fig. 393). 
The initial opening through the Vjone should be made in this fossa. As 
the outer wall of the antrum is approximately one-half inch below the 
surface, it is still necessary to determine its position in relation to the 
postsuperior wall of the meatus. It is usually situated close to this wall; 
hence it is necessary to determine the direction it pursues from the sur- 
face of the mastoid process to the fundus of the ear. This is readily done 
by the introduction of a straight probe into the meatus against the post- 
superior wall. Its direction is usually forward, downward, and inward. 
Whatever the direction, the opening in the mastoid fossa should be 
extended inward parallel with the probe as it stands against the post- 
superior wall of the meatus. I have never known these guides to fail 
in locating the antrum. The suprameatal triangle (Fig. 393) is another 
fair guide to the antrum, though not as good as the mastoid fossa. 

The location of the sigmoid sinus in its relation to the mastoid cortex 
and to the posterior wall of the external auditory meatus may be rather 
accurately determined by noting the contour of the mastoid process and 
the relation of its surface to the external auditory meatus. According 
to'AVhiting, the following^landmarks are of great value in locating the 
lateral sinus: 



THE PHYSIOLOGY OF THE EAR 577 

A broad flat mastoid process sloping gradually toward the brow of 
the meatus, with the posterior wall of which it unites at a very slight 
angle, indicates that the sinus is not near the meatus. The gradual 
mergence of the surface of the mastoid surface into that of the posterior 
wall of the meatus also indicates that the sinus is deeply situated. 

A convex rounded mastoid process is indicative of a superficially 
located lateral sinus. Caution should be exercised in opening such a 
mastoid process, lest the sinus be wounded. 

A wide meatus entering the bone almost vertically to the mastoid 
surface is an indication that the sinus is located well forward close to the 
posterior wall of the meatus. 

A dolichocephalic skull is indicative of large pneumatic cells, hence 
in such a skull the pneumatic cells of the temporal bone are liable to 
be widely distributed. In a case described by Whiting they extended 
toward the occiput and over the root of the zygoma as far forward as 
the apex of the glenoid fossa. 



THE PHYSIOLOGY OF THE EAR. 

I. Membrana Tsrmpani. — The eardrum is stretched across the inner 
end of the external meatus, and is elastic enough to undergo considerable 
movement when the air in the meatus is alternately condensed and rare- 
fied with Siegle's otoscope. The membrane is attached to a groove in 
the annulus, the sulcus tympanicus, by an extension of the periosteum of 
which the middle or fibrous layer is composed. The annulus tympanicus 
does not extend completely around the meatal opening, but is absent at 
the upper portion, the Rivinian segment. The part of the membrane 
attached to the annulus is known as the pars tensa or the membrana 
tensa. The part attached to the Rivinian segment is not stretched, but is 
loosely drawn, and is known as Shrapnell's membrane, the pars flaccida 
or the membrana flaccida. This portion of the membrane forms the 
outer wall of Prussak's space, while the pars tensa forms the lower 
portion of the outer wall of the tympanic or middle-ear cavity. 

The membrane is not placed perpendicularly across the opening of 
the meatus, but forms an angle of about 140 degrees with the postsuperior 
wall, and one of 45 degrees with the antero-inferior wall. This is of 
clinical importance in the removal of foreign bodies from the meatus. 

The function of the membrana tympani is to receive and convey sound- 
waves to the chain of ossicles, and thence to the labyrinth. That it is 
not absolutely essential to fair hearing is shown by the fact that good 
hearing is often present when the membrane is perforated or entirely 
absent. The eardrum also protects the tympanic membrane from the 
deleterious effects of the air and from the entrance of morbific germs and 
foreign bodies. 

When the normal tension of the driiinhcad is distributed tluTe is an 
impairment of hearing, hence any morbid condition of the Eustachian 
tube which interferes with the ventilation of the tympanic cavity, or any 
37 



578 THE EAR 

inflaiiiinatorv disease of the mucous meni])raiie which interferes with the 
mobiUty of the ossicuhir chain, or any morbid condition of the drumhead 
itself whicli interferes with its elasticity or motility, will cause more or 
less deafness. 

II. The Eustachian Tube. — The function of the Eustachian tube 
is twofold, namely, (a) to ventilate, and ((6) to drain the tympanic and 
mastoid cavities. When these spaces are healthy, the Eustachian 
tube is adequate for the purpose. When, however, the spaces are 
inflamed, and the secretions are greatly increased in quantity, it is not 
large enough to accommodate the passage of the secretions into the 
epipharynx. When its capacity is thus overtaxed, the retention of the 
secretions causes pressure necrosis in the direction of least resistance, 
namely, the memlirana tympani. Perforations thus arise in the course 
of infective inflammations of the tympanic cavity, the antrum, and mastoid 
cells. The Eustachian tube is generally large enough to carry off the 
secretions from the tympanic cavity, even when in a diseased state, but 
when in addition the antrum and mastoid cells are involved it is not 
capable of disposing of the secretions, retention occurs, and the pressure 
symptoms (pain, tenderness and swelling) of mastoid inflammation ensue. 
If the excess of secretions from the antrum and the mastoid cells 
are diverted from the tympanic cavity, the morbid process in it tends 
to get well because the tube is large enough to drain the secretions from 
the tympanic cavity. In other words, the retention of the secretions in 
any cavity tends to foster inflammatory processes in the mucous mem- 
brane, which may, in time, extend to the periosteum and the bone to 
which it is attached. (See Diseases of the Nasal Accessory Sinuses, 
the Clinical iVnatomy of the Tonsils, and Heath's Mastoid Operation.) 

The Tympanic Cavity. — The function of the tympanic cavity and its 
contents is to transmit sound waves to the labyrinth. It also forms a 
channel of communication between the Eustachian tube and the epi- 
pharynx, on the one hand, and the antrum and mastoid cells on the other. 
The cavity is divided into two spaces by the interlocking heads of the 
malleus and incus. The lower space is called the atrium, or the middle 
ear proper, while the upper is called the attic. The attic is still further 
subdivided by the heads of these bones into an inner and an outer attic. 
The outer space is divided into an upper and a lower space by the exter- 
nal ligament of the malleus (Fig. 334). The lower space is called 
Prussak's space, which, when it becomes the seat of suppurative inflam- 
mation, is difficult to cure. (See Suppuration of Prussak's Space.) 

The inner wall of the tympanic cavity presents two anatomical features 
of physiological and clinical interest, namely, the oval and round windows. 
The oval window, the fenestra vestibuli, receives the foot plate of the 
stapes, which is surrounded by the annular ligament, and communicates 
with the vestibule of the labyrinth. The round window opens into the 
cochlea, and the membrane closing it forms an elastic valve to relieve 
the shock to the cochlea in the presence of excessive sound waves. 

The Tegmen Tympani. — The roof of the attic, the tegmen tympani, 
consists of a thin bony wall whicli separates the tympanic cavity from 



THE PHYSIOLOGY OF THE EAR 579 

the cranial cavity. When there is a retention of purulent secretions, the 
periosteum and the bone it covers may undergo caries and necrosis, and 
thus expose the meninges and the brain to infection. (See Intracranial 
Complications and Sequelae to the Middle Ear and Mastoid Diseases.) 

The Tegmen Antri. — The tegmen antri, or roof of the antrum, is a 
little thicker than the roof of the attic, and is often the seat of necrosis 
and perforation in spite of this fact. This is probably due to the 
small size of the aditus ad antrum. Being small, it is easily occluded by 
the inflammatory swelling of its lining mucous membrane, and the usual 
destructive processes attending the blockage of mucous membrane- 
lined cavities ensue; that is, the infectious inflammatory process is 
perpetuated and is attended by the destruction of tissue in the direction 




Coronal section through the tympanum, a, extremity of the upper; 6, extremity of the lower 
bony wall of the meatus; d, tegmen tympani; ee, attic, external portion, internal portion; 
f, malleus and superior ligamentimi mallei; 2, incus; A, stapes within the fenestra vestibuli; i, 
promontory; k, Prussak's space; ni, hyiDotympanic recess (cellar); I, scar in the lower half of the 
drumhead in apposition with the promontory; 2, incudostapedial junction. (After Briihl-Politzer.) 

of least resistance, namely, the tegmen antri and the postsuperior wall 
of the inner end of the external meatus. Bulging and redness of the 
postsuperior wall of the meatus near the drumhead is, therefore, a 
common symptom of antral supjjuration. 

The Intrinsic Muscles of the Ear. — The tensor tympani muscle pulls 
the handle of the malleus inward, ihus increasing the tension of tlie drum- 
head. This movement of the malleus is communicated to the long pro- 
cess of the incus, which in turn acts upon the stapes and compresses it 
into the oval window. Prolonged retraction of the membrana tympani 
is attended by a shortening of the tendon of the muscle, a condition which 
materially interferes with the cure of the deafness resulting from these 
conditions. The stajx'dins muscle acts in antagonism to the tensor 
tympani, and counterbalances the compression of the foot plate of the 



580 THE EAR 

stapes in the oval window. The membrana tympani, the circular 
ligament of the oval window, and the interposed chain of ossicles are 
thus poised to receive the sound waves and transmit them to the cochlea, 
where the impression is received by the delicately attuned organ of 
Corti of the cochlea, which in turn transmits the impression to the audi- 
tory centre of the brain, where it is perceived as soimd. 

It is apparent from the foregoing physiological data that it is of great 
therapeutic value to maintain free drainage and ventilation of the middle 
ear and its accessory cavities, and to prevent the morbid changes incident 
to the inflammatory processes of the middle ear. 

The Physiology of the Sound-perceiving Apparatus.— The sound- 
perceiving apparatus is composed of the terminal nerve filaments of 
the labyrinth, the acoustic (auditory) nerve, and the auditory centre in 
the brain. 

The Auditory Nerve. — The auditory nerve arises between the facial 
and glossopharyngeal nerves in the medulla oblongata, and passes into 
the internal auditory canal, in the fundus of which it divides into two 
branches; the vestibular branch (nerve) enters the vestibule, where it 
sends twigs to the utricle and the superior ampullae of the semicircular 
canals; the cochlear branch (nerve) passes into the cochlea and gives off 
twigs to the saccule and to the ampulla of the superior semicircular canal. 

The distribution of the auditory nerve in the cochlea forms a spiral 
ganglionic ribbon, the ganglionic cells being connected by medullated 
nerve fibers, the whole being supported on the membranous cochlea, 
which is attached to the osseous cochlea by fibrous bands. The mem- 
branous labyrinth is filled with a fluid called endolymph, and is sur- 
rounded by a fluid called the perilymph. The cochlear distribution of 
the auditory nerve is called the organ of Corti. 

The Function of the Vestibular Apparatus. — Within the vestibule (saccule 
and utricle) the otoliths, acting upon the delicate hair-like prolongations, 
preside over the sense of the position of the head (body) in space. The 
angle of the impact of the otoliths upon the hair-like processes (the 
relative bending) creates a sensation which, being interpreted by the brain 
centres, gives conscious knowledge of the relative position of the head 
(body) to the line of gravity and consequently to the plane of the earth. 
In other words, they aid in the maintenance of equilibrium. 

The Function of the Semicircular Canals. — These canals are the organs of 
coordinated movements, or statical sense, hence they are also a part of 
the apparatus presiding over the sense of equilibrium. 

The Function of the Cochlea. — Corti's cells constitute the true terminal 
acoustic (auditory) nerve apparatus. They are about 2000 in number 
and are ciliated. The function of the cochlear apparatus is to perceive 
and differentiate sound waves, and convey them to the auditory nerve 
trunk, thence to the acoustic centres of the brain, where they are perceived 
as sound. 

Shambaugh controverts the theory of Helmholtz that the basilar 
membrane is the resonator of the internal ear. According to Helm- 
holtz, the fibers of this membrane vibrate in sympathy with the sound 



THE PHYSIOLOGY OF THE EAR 581 

waves as they react upon the labyrinth and thus stimulate the hair cells 
of the organ of Corti. Shambaugh's conclusions are ingenious, and 
are as follows (Plate X) : 

1. "The hair cells of the organ of Corti are the real end organs wherein 
the physical impulses of sound waves are transformed into the nerve 
impulses, which result in tone perception. 

2. "The perception for the various tones takes place in different parts 
of the cochlea, those of higher pitch being taken up by the hair cells 
located near the beginning of the basal coil, those of lower pitch by the 
cells near the apex of the cochlea. 

3. "The stimulation of the hair cells is effected only through the 
medium of their projecting hair. 

4. "The hypothesis that each hair cell acts as its own agent in selecting 
its stimulus from the impulses passing the endolymph is shown to be 
untenable for a number of reasons, chiefly, however, because the relation 
existing normally between the hair cells and membrana tectoria will not 
permit of these impulses in direct contact with the hair cells. I have 
shown conclusively that the hairs of the hair cells project normally into 
the under surface of the membrana tectoria. 

5. "The stimulation of the hair cells is accomplished only through an 
interaction between the hairs of the hair cells and the membrana tectoria. 

6. "The hypothesis of Helmholtz that this stimulation is brought about 
through the vibration of the fibers of the membrana basilaris is untenable, 
especially for the following reasons: In tracing the membrana basilaris 
toward the beginning of the basal coil in the vestibule this structure is 
found at a considerable distance from the lower end of the coil, and where 
a perfectly formed organ of Corti is still present to become so stiff and rigid 
as to render it incapable of vibrating. Even a complete absence of a 
basilar membrane m this locality is sometimes noted. The logical 
conclusion is that since the stimulation of the hair cells in this locality 
is accomplished without the intervention of a vibrating membrana 
basilaris, therefore the stimulation of the hair cells throughout the 
cochlea is not dependent on the vibration of this membrane. 

7. "The logical conclusion is that the stimulation of the hair cells is 
accomplished through vibrations of the membrana tectoria transmitted 
to it by impulses passing through the endolymph. 

8. "The membrana tectoria is shown to be so constituted anatomically 
as to be capable of responding to the most delicate impulses passing 
through the endolymph. Furthermore, the great variation in size of 
this membrane from one end of the cochlea to the other, together with its 
lamellar structure, suggests the probable physical basis which renders it 
capable of acting the part of resonator by responding in one part to 
impulses of a certain pitch, and in another part to impulses of another 
pitch (Fig. 335). 

9. "Finally, the pathological phenomena of 'tone islands,' 'diplakousis 
binauralis of dysharmonica,' and of 'tinnitus aurium' are all plausibly 
accounted for in this conception of the physiology of tone perception. 

10. "To restate briefly the process by which the phenomenon of tone 



582 



THE EAR 



perception is accomplished: The sound waves conducted from the air 
impinge upon the membrana tympani, producing vibrations in it. 
These vibrations conducted along 'the chain of ossicles transmit impulses 
to the intralabvrinthine fluid througii the medium of the foot plate of 
the stapes. TJie impulses originating in the fluid in the vestibule pass 
directlv into the scala vestibuli and through the membrane of Reissner 




Lv, labium vestibularis; Mt, membrana tectoria; Lt, labium tympanse; Mb, raembrani 
basilaris; LS, ligamentum spiralae; SH, striefen of Hensen. 



to the endolymph, where sympathetic vibrations are imparted to the sev- 
eral parts of the membrana tectoria, depending on the pitch of the tone. 
The vibrations in turn stimulate the hairs of the hair cells which normally 
project into its under surface. The nerve impulses originating from all 
the hair cells thus stimulated by a particular tone come together in the 
brain centre in the cortex when the tone picture forms the final step in 
the process of tone perception." 



CHAPTER XXXIIL 

THE FUNCTIONAL TESTS OF HEARING. 

The value of the functional tests of the organ of hearing as aids in 
diagnosis and prognosis in diseases of the ear have for more than three 
generations been a controversial subject. In spite of this fact, they are 
still recommended by the great authorities on otology. Much dis- 
cussion has arisen because of certain exceptions to the general rules laid 
down by various writers, or on account of an imperfect understanding 
of the principles underlying the physiological experiments. The fact 
that they have been used by three generations of otologists, and that they 
are now more generally used than ever before, is a fair indication of 
their utility and of their fixed place in otological practice. 

I can do no better than quote Prof. A. Politzer in this connection : "The 
tests for hearing are of the greatest importance in the diagnosis of the 
diseases of the ear; for they serve not only to determine the extent of the 
disturbance of hearing, but not infrequently also to localize the affection, 
inasmuch as in cases in which the other objective methods of examination 
give a negative result we are enabled to judge whether the anatomical 
cause of the functional disturbance has its seat in the apparatus for the 
conduction of sound or in the nerve apparatus. But they are also of 
special value because by means of them, while the patient is under obser- 
vation, we can note the course of the disease and also the result of treat- 
ment." 

Some Physiological Facts. — (a) The normal range of hearing, in 
man, for musical tones is from 16 to about 48,000 vibrations per second. 
After the fiftieth year the upper limit of hearing is somewhat lowered. 
Persons seventy or more years old do not usually hear tones of more than 
37,000 vibrations per second. 

(b) Paths through Which the Sound Waves Reach the Lab3rrinth. — 
1. Sound waves reacii the labyrinth chiefly through the tympanic 
membrane, the ossicles, and the oval window into which the foot plate 
of the stapes is inserted. The foot plate does not form a bony union 
with the oval window, but is attached to it by a fibrous membrane or 
ring. This allows it to vibrate in the window. Politzer demonstrated 
that the malleus performed the greatest excursions, the incus less, and 
the stapes least of all. Ilelmholtz found the greatest excursions of the 
stapes to be y^ to jj mm. It is obvious that slight interference with the 
movements of the foot plate either by adhesive bands or ankylosis at the 
window wi.l materially interfere with the transmission of sound waves 
to the labyrinth, and thus impair the function of hearing. 

2. Sound waves also reach the labvrinth thron*!,!) (lie fencsli-a coclilea 



584 



THE EAR 



(round) window, hence the function of tlie ear is not altogether destroyed 
when the foot phite is fixed. 

3. Sound waves are also carried to the labyrinth to a considerable 
extent through the bones of the skull (Fig. 336). This explains the 
somewhat startling fact that deaf persons hear tolerably well if the 
speaker places the tips of his fingers against the forehead of the listener. 
Weber's well-known experiment demonstrates that when a tuning fork 
of 512 vibrations is placed upon the skull and the external meatus is 
artificially closed with the finger, the vibrating fork is heard much better 
on that side. In other words, bone conduction is thus increased. Though 
it is thus increased in intensity, it is still less than by air conduction. 




Air and bone conduction (schematic). 1, cranium; 2, cerebrum; 3, auditory nerve going to 
temporal lobe; 4, labyrinth; 5, tympanum and auricles; 6, auditory meatus; 7, pinnae; a, tuning 
fork placed on the vertex; ah, osteal bone conduction; ac, craniotympanal bone conduction; d, 
tuning fork held in front of the ear; dc, air conduction. (After Briihl-Politzer.) 



In the normal ear hearing by bone conduction for tuning forks is 
a little more than one-half of that for air conduction. The relative 
duration of hearing by bone and air conduction varies greatly with differ- 
ent forks of the same number of vibrations. It will also vary with the 
point of contact made with the fork. For example, it is heard a little 
longer when placed over the mastoid antrum than when placed on the tip. 
It is customary with most otologists to place it between these two points, 
just posterior to the external meatus. Politzer has called attention to 
the varying results obtained by forks of the same number of vibrations. 
Each set of forks should therefore be carefully and repeatedly tested 
upon normal cases, so as to establish their normal register. By normal 
register is meant the length of time the fork is heard in normal ears by 
bone conduction when placed over the mastoid just back of the external 



THE FUNCTIONAL TESTS OF HEARING 585 

auditory meatus, and the time it is heard by air conduction when held as 
near as possible to the auditory meatus. Gradenigo, at the London 
International Congress of Otologists, gave a scheme for the uniform 
record of the functional tests, in which he gives the registers of the forks 
used. This should be done by all observers. In this way the records 
will be of uniform standard and value. 

(c) The tensor tympani and the stapedius muscles have long been 
regarded as the tension regulators of the ossicular chain, the stapedius 
counterbalancing the tensor tympani. A few years ago Dr. T. F. 
Rumbold wrote an article to the effect that they were the tone-selecting 
muscles of the ear, just as the ciliary muscles are the viewpoint selectors 
of the eye. In other words, that they are the focusing muscles of the 
ear. He says that through their action the ear is enabled to select a 
particular voice from a multitude of voices; and that they attune the 
drumhead to catch and transmit to the labyrinth the sound waves 
selected at will by the listener. 

(d) The normal ears of a given subject perceive sound in its actual 
pitch. Both ears perceive it exactly alike. They perceive sound co- 
ordinate in pitch, timbre, and intensity. In certain pathological states 
one or both ears may get "out of tune." 

Principles Underlying the Tests of Hearing.— 1, The normal range 
of hearing is from 16,000 to 48,000 double vibrations per second. 

2. When the conduction apparatus is diseased or obstructed, the power 
to hear high tones is impaired or lost. 

3. When the perception apparatus is diseased, the power to hear high 
tones is lost. 

4. The normal ear hears about twice as long by air conduction as by 
bone conduction. That is, a fork heard by bone conduction for twenty 
seconds will be heard about forty seconds when held close to the ear. 

5. When the conduction apparatus is diseased or obstructed, bone 
conduction is increased and the time left in which the fork should be 
heard by air conduction is diminished; or bone conduction may be so 
much increased that the fork is heard longer than by air conduction. 

6. When the perception apparatus is diseased, bone conduction is 
diminished or shortened, so that the relative time of hearing by air con- 
duction is exaggerated. 

The Practical Application of the Functional Tests,— We are 
now ready to discuss the application of some of the most approved 
pliysiological experiments pertaining to the ear, with the hope of arriving 
at some conclusion as to their value as aids in diagnosis and prognosis. 
It is not assumed by the writer that a correct diagnosis cannot usually 
be made, or at least fairly accurately guessed at, without the use of the 
functional tests. We grant as much. The only question herein dis- 
cussed is as to the reliability of the tests in those cases in which there is 
some doubt as to the diagnosis. The otologist should, however, make 
constant use of the tests, in order that he may become skilful in tlieir 
application and in his deductions therefrom. It is necessary, tliercfore, 
to make it a routine practice of applying them to all or nearly all cases 



586 THE EAR 

coming under the observation of the physician. The writer has for 
several vears made this his practice in both private and chnical work, 
and he feels that he has been well rewarded for his trouble. The convic- 
tions herein expressed are based upon this experience. 

The Watch Tests. — This instrument has long been used to test the 
acuteness of hearing, and is of more or less value. The patient may be 
able to hear the watch distinctly at about the normal distance, and yet not 
understand conversation, or vice versa. ^Yhile it may not afford an 
accurate means of diagnosis, it is often the means by which comparisons 
may be readily made from time to time during the progress of treatment. 
In catarrhal inflammation of the middle ear, and especially of the Eusta- 
chian tul)e, the watch may be heard distinctly one day, and indistinctly, 
or not at all, another day. This variation is rather diagnostic of this type 
of ear disease, and is accounted for by the intermittent stoppage of the 
lumen of the tube and the subsequent absorption of the oxygen from 
the middle ear. When the tube becomes clear again air is restored to 
the tympanic cavity, and the normal tension of the drumhead and the 
ossicular chain is restored. I use two watches, one a high-pitched ticker, 
the other a low one. The low-pitched ticker is the one dollar Ingersoll 
watch, which can be heard at a distance of one hundred and twenty 
inches, while the high-pitched ticker (a Paillard's non-magnetic Swiss) 
can l)e heard at five feet. 

Prout's method of recording the result of the test is used, i. e., the num- 
ber of inches the watch is heard by the normal ear is used as the denomi- 
nator, and the distance at which it is actually heard as the numerator. 
Thus, if the Paillard, or high-ticker, is used, and is heard at ten inches, 
the fraction i}} expresses the result. If the loud-ticker is used, and is 
heard at thirty inches, the fraction yyV expresses the result. There 
are five ways of using the watch, namely: (a) Finding the distance at 
which it is heard upon approaching the ear; (6) placing it in firm contact 
with the auricle; (c) placing it against the mastoid process; (d) placing it 
between the teeth and noting in which ear it is heard the plainer, as in the 
Weber experiment; and, finally, (e) after first finding the distance at which 
the watch is heard upon approach, and then noting how much farther 
it can be heard upon withdrawing it from the ear. As before stated, 
Rumbold uses the latter test to ascertain a tonicity of the middle ear 
muscles. The writer has also used it for the same purpose for the last 
eight years and finds improvement in atonic cases following the admin- 
istration of strychnine and iron, and rest and outdoor exercise. W'hether 
this is due to increased tonicity of the muscles or other causes I will not 
attempt to state. 

The Voice Test. — In 1S71, Oscar Wolf published his conclusions as to 
the voice as a means of testing the organ of hearing. He found the 
letter R to be the lowest in the scale, having 128 vibrations per second, 
while the highest number of vibrations was given by S which gave from 
5400 to 10,S40 vibrations per second. Hence, by the use of these conso- 
nants we may test the hearing for the lower and within two octaves of 
the highest musical tones. With marked limitations this experiment may 



THE FUNCTIONAL TESTS OF HEARING 



587 



be used to differentiate between disease of the middle ear and of the 
labyrinth. In other words, he found speech to be confined within about 
6y octaves. The greatest strength and timbre belong to the vowel A 
which can be heard 252 m., and the smallest to the consonant H, which 
can be heard 8.4 m. distance. He classifies the various sounds and letters 
so that they may be used for testing purposes. There are several objec- 
tions to this method of testing, in spite of the great amount of scientific 
investigation bestowed upon it by Wolf, Clarence Blake, and others. If 
words are used, the patient often hears the vowel sounds distinctly, and 
if numerals, he experiences the same difficulty with the additional one 
of attempting to infer the number by sequence. Then, too, there is the 
difference in quality, timbre, pitch, and carrying quality of the voices of 
different observers. This difference is less pronounced in the whispered 
voice, especially if it is given out with the residual air. In fact, when 
the whispered voice is used it should 

be given only with the residual air, Fig. 337 

thus rendering all voices more nearly 
alike. An intelligent application of 
this method will aid in diagnosis, 
and in noting the progress made 
under treatment. 

Dr. Harry Kahn recently called 
attention to Politzer's method of 
lengthening the room when it is too 
short to test he hearing by the voice. 
The examining surgeon, when at the 
extremity of the room, by turning 
his back to the patient increases 
the distance by one third. If the distance is still too short, it may 
be increased to two-thirds by turning the patient's bad ear to the 
opposite wall. 

The Politzer Acoumeter. — This instrument (Fig. 337) was designed to 
take the place of the watch, or at least to supplement it, and can be heard 
at about 40 feet. All of the instruments are supposed to be of the same 
pitch and timbre, but in the mad rush of American dealers I fear 
little attention has been given to their exact construction. It is, however, 
a valuable adjunct to the watch tests, and may be applied in the same 
way, 40 feet being taken for the denominator, and the actual number of 
feet at which it is heard as the numerator. Politzer and Lucae claim it 
more nearly corresponds with the voice test than either the watch or 
the distance test with the tuning forks. 

Many ingenious physiological tests of more or less value have been 
devised, but, after all, the most valuable are those made with the tuning 
U)vks and the whistles. We will now proceed to discuss some of the more 
valuable ones. 

The Range of Hearing.— As already stated, the normal range of 
lu^aring for adults uudcr fifty years of age is from Ki vibrations to 4S,000 
per second. After llie fiftieth year this may be reduced to 37,000 })er 




Politzer's acoumeter. 



588 THE EAR 

second. In other words, the upper register is lowered by the changes 
incident to senility. The range of hearing varies in different individ- 
uals according to age and the pathological condition of the auditory 
apparatus. The lowest tones perceived are between 16 and 23 vibrations 
per second (Pyer), while the highest audible tone is e^ wnth 40,960 vibra- 
tions (Landois and Stirling). In youth the upper limit is about one 
octave lower, or e', with 20,480 vibrations per second. In beginning 
senility it is about a" or 13,653 %abrations, while in very old persons it is 
near g" or 12,288 vibrations per second (Zwaardemaker). 

The foregoing data should be borne in mind in estimating the probable 
significance of tests of the range of hearing, as it is apparent that there 
is no fixed upper limit of hearing, since it varies in the same individual 
at different periods in his life. There is also quite a distinct variation in 
different individuals of the same age. Any marked variation, however, 
from the above figures would in most instances mdicate the presence of 
some pathological process within the auditory apparatus. 

Fig. 338 





Testing the hearing with the Galton-Edlemann whistle at eighteen inches 

By referring to the third principle (p. 585) we find that high tones are 
diminished or lost in disease of the perception or nerve apparatus, hence, 
in applying this principle, the age of the patient should be taken into 
account. The upper limit of hearing is also lost in certain conditions 
of the middle ear, notably in marked retraction of the membrana tympani, 
whereby the foot plate of the stapes is forced inward against the laby- 
rinthine fluid. This increased pressure so affects the terminal endings 
of the auditory nerve as to interfere with the perception of high tones. 
This condition can usually be differentiated from true labyrinthine or 
nerve deafness by inflation of the middle ear. This procedure usually 
restores the normal tension to the membrana tympani and the ossicles, 
and thereby relieves the increased intratympanic tension. The upper 
limit of hearing being restored, the diagnosis can easily be made. 

The best outfit for making a complete test of the range of hearing is 
the Bezold-Edlemann set of forks and whistles. With these every 
musical tone from 16,000 to 48,000 vibrations can l)e tested. This is 



THE FUNCTIONAL TESTS OF HEARING 589 

very important in certain cases, especially in deaf-mutes. It is a well- 
known fact that a large percentage of so-called deaf-mutes are not totally 
deaf, but only to such an extent that they do not hear well enough to 
acquire speech. Then, too, some of them have oases of hearing, only 
perceiving certain tones in the entire range of hearing. In such cases 
these tones should be ascertained, and the patients should be trained to 
distinguish sounds, musical tones, and speech at these pitches. The 
information gained by this simple method may be made the avenue 
through which some of these poor unfortunates are brought within the 
range and influence of the greatest pleasure in life, namely, social con- 
versation with their fellows. Hartmann's set of tuning forks (Fig. 339) , 
while it is very abbreviated, answers very well for the ordinary examina- 
tions. It is not, however, free from overtones, and does not measure 
the lower range of hearing. The Galton whistle gives the upper range 
of hearing. 

By referring to the second principle (p. 585), we find that in disease of 
the conduction apparatus the power to hear tones of the lower register is 




Hartmann's set of tuning forks. 

impaired or lost. Loss of hearing for low tones is, therefore, usually 
a sign of tubal catarrh, middle-ear disease, or obstruction of the external 
meatus. It must not be forgotten, however, that the portion of the nerve 
apparatus concerned in the perception of low tones may be diseased, 
while the other parts are not affected. In this case the loss of low tones 
would not signify middle-ear disease. These cases are exceedingly rare, 
and would not, therefore, often confuse the observer. 

The Weber Experiment. — This is one of the best-known and most 
reliable tests made with the forks. Weber's experiment consisted in 
placing the tuning fork c^, 512 v., on the median line of the skull, and 
then closing the external meatus of one ear with the finger, under which 
condition he found the sound lateralized toward that ear. Clinically 
it has been shown that when the middle ear is diseased, or the external 
meatus is obstructed by cerumen or other morbid conditions, the sound 
for the vibrating tuning fork (when on the median line of the skull) is 



590 



THE EAR 



lateralized to the affected ear; and that when the labyrinth is affected 
the sound is laterah'zed toward the unaffected ear. This rule, like all 
rules, has exceptions. If the middle ear and the labyrinth are both 
affected, there are manifestly two opposing conditions, one increasing 
and the other decreasing bone conduction (Figs. 340 and 341). 




teo^ 




Fig. 340. — The Weber experiment witli the c- tuning fork. The patient is deaf in Ihe left ear 
and the sound lateralizes to the left ear, thus indicating disease of the sound-conduction apparatus 
of the left ear. 

Fig. 341. — The Weber experiment with the c- tuning fork. The patient is deaf in the left ear 
and the sound lateralizes to the right or good ear, thus indicating disease of the perception appa- 
ratus (labyrinth) of the left ear. 



In such cases dependence must be placed upon a much more extended 
examination. Indeed, dependence should rarely, if ever, be placed upon 
a single test. 

Another exception to the rule, which has been noted by several 
observers, is often found in cases in which both middle ears are affected, 
but unequally. Ordinarily the fork is lateralized toward the side most 
affected,^l)ut the opposite is often true. Hence, in bilateral deafness 
the Weber experiment is not so reliable as in unilateral deafness. 



THE FUNCTIONAL TESTS OF HEARING 591 

In simple or uncomplicated labyrinthine disease, however, the fork 
is almost universally lateralized toward the good ear. Jacobson and 
Politzer have never seen an exception to this rule in undoubted cases. 
The test seems, therefore, to be a reliable one in this class of cases. 

The accuracy of the Weber test will depend very much upon the fork 
used. In nearly all cases the best results are obtained with fork c^, 
512 v. Occasionally better results may be had with lower ones. Forks 
of more frequent vibrations should not be used, as they often give exactly 
the opposite result. They are, therefore, useless for making this test. 
In exceptional cases a c^, 512 v., fork may not be at all adapted for this 
test. When we remember that a fork of a higher pitch should never be 
used, we can readily understand why a c" fork with marked overtones 
should not be used. The high overtones might so counterbalance the 
true tone of the fork that it would be a question as to which was referred 
to by the patient in response to the test. 

According to Politzer, when the patient is in doubt as to which ear per- 
ceives the sound, the sound will be lateralized if ear specula are inserted 
in both external meatuses. He also calls attention to the fact that in 
double chronic middle-ear disease the sound of the fork may be lateral- 
ized to one side when placed on the vertex, and to the other when placed 
on the maxilla or the bridge of the nose. 

The Weber test is, therefore, found to be the more reliable in uni- 
lateral middle-ear disease, somewhat less reliable in labyrinthine disease, 
and still less reliable in double chronic middle-ear affections. 

The Schwabach Test. — The Schwabach test is made with a vibrating 
A fork, by first placing it upon the vertex of the examining surgeon 
until it ceases to be heard, and then transferring it to the vertex of the 
patient, note being made of the relative length of time the fork is heard 
by the surgeon and the patient. It has been shown by Siebenmann, 
Bezold, Hollinger, and others that in hyperostosis of the bony capsule 
of the labyrinth (spongifying), bone conduction for this fork is greatly 
prolonged, i. e., ten to sixty seconds. In view of this fact, the Schwa- 
bach test is often of great assistance in diagnosticating this disease. 

The Rinne Test. — In this test only the difference between bone and air 
conduction is recorded. For instance, if bone conduction is twenty-five 
seconds and air conduction is fifteen seconds, it is recorded negative 
Rinne, or Rinne — 10". If air conduction is ten seconds longer than 
bone conduction it is recorded positive Rinne, or Rinne+10". If 
hearing by air conduction exceeds that by bone when applied to the deaf 
ear, there is nerve deafness; and when bone conduction exceeds that l)y 
air when the fork is applied to the deaf ear there is middle-ear deafness. 
This test is not so reliable as the Welder, but is nevertheless one that 
should always be used in conjunction with the other tests (Figs. 342 
and 343). 

According to Lucac the Rinnd test is only reliable when hearing for 
whispered conversation is reduced to 1 m. 

If there is increase of bone conduction to such an extent that a negative 
Rinne is obtained, the test is reliable. If, however, bone conduction is 



592 



THE EAR 



only increased to a moderate extent and a plus Rinne is obtained, it 
does not afford much information. The more profound the deafness 
from the middle-ear disease the more reliable is the test. 

If tliere is a correspondence between tlie results of the range of hear- 
ing, Weber, and the Rinne tests, the latter is additional proof of the 
pathological condition j>resent. Thus if a patient complains of deafness 
in the right ear, and the Weber test lateralizes the soinid to the right side, 
and the Rinne— 10", the Rinne corroborates the other tests and confirms 
the other signs pointing to middle-ear disease. There are many cases 
in which the diagnosis is in doubt when the information afforded by the 
various physiological tests renders the diagnosis clear. When, however, 
there is a minus Rinne, with duration of bone conduction also shortened, 
there may be some doubt as to the significance of the negative or minus 
Rinn^. In such cases there may be present both middle and labyrin- 





FiG. 342. — Showing the Rinn^ a fork in position on the mastoid process in the Rinne test. 
Fig. 343. — Showing the Rinn^ a' fork held close to the ear in Rinn^'s test. 



thine disease. This apparently anomalous result is often very signifi- 
cant, and should lead to most careful investigation and to a very guarded 
prognosis as to the hearing. It is often the case that, through the very 
contradictions arising from the tests, we are enabled to arrive at a 
correct idea as to the location and extent of the pathological process. 

In middle-ear disease, affecting one side only and of moderate degree, 
the Weber is the more reliable test. 

In the aged the Rinne test is not so reliable, on account of the diminished 
bone conduction incident to senility. 

In marked deafness, when the Rinne gives a positive result (plus Rinne), 
it is a fairly reliable sign of nerve involvement. 

The tuning fork liest suited for making this experiment is a', although 
it maybe made with higher pitched forks. With higher forks than a' it 
is, however, difficult to eliminate hearing by air conduction. Unlike the 



THE FUNCTIONAL TESTS OF HEARING 593 

Weber, the lower forks are not suited to this test, as upon the mastoid the 
patient cannot so easily distinguish between the mechanical vibrations 
and the tone of the fork. 

The fork used should have its register established by numerous experi- 
ments upon normal ears, and in publishing reports of cases this register 
should be named (unless the Bezold-Edlemann forks are used) . 

The Gelle Test. — This test is based upon the physiological experiment 
of compressing the air in the external auditory meatus, while the vibrat- 
ing fork is upon the vertex. At the time of compression the perception 
for the tone of the fork is greatly diminished in a normal ear. This is 
due to the increased pressure within the labyrinth. According to Gelle, 
if there is ankylosis of the foot plate there will be no change in the tone; 
he therefore claims it is of value in diagnosticating this condition. On the 
other hand, if there is marked deafness and the tone is greatly diminished 
with each compression of the air in the meatus, it signifies that the foot 
plate is freely movable and that deafness is due to labyrinthine disease. 
The compression should not be made with the finger inserted into the 
meatus, but should be done with a Delstanche masseur and Siegle's 
otoscope, or some other contrivance which will drive the drumhead and 
the ossicles inward compressing the labyrinthine fluid, and even then 
it often fails to afford information. 

Bing Test, No. 1. — This test is also used to differentiate between middle- 
ear and labyrinthine affections. The experiment is based upon the fact 
that when the tuning fork upon the mastoid ceases to be heard, it is 
heard anew wdien the external meatus is closed with the finger. In cases 
with pronounced deafness, if closing the meatus does not develop the 
tone anew, it is, according to Bing, a sign of middle-ear disease, whereas 
if it is heard again (in cases of pronounced deafness), it is a sign of laby- 
rinthine disease. This test seems to be of value only in very severe deaf- 
ness. 

Bing Test, No. 2. — This test is usually referred to as the "entotic" use 
of the speaking tube. The purpose of the test is to differentiate between 
ankylosis of the foot plate of the stapes and adhesive bands or other 
pathological conditions which hinder the malleus'and the incus in trans- 
mitting sound waves. The test is made by comparing the hearing of a 
patient through a speaking tube applied to the external meatus and one 
applied through the Eustachian catheter. If the patient hears better 
through the speaking tube by way of the catheter than he does through 
the external meatus, the inference is that the foot plate is freely movable, 
while the malleus and the incus are fixed or hindered in their vibrations. 
If such is the case, a rational treatment is at once suggested, i. e., either 
the freeing of the malleus and the incus from the adhesions or other 
hindrances, or the removal of one or both ossicles, preferably only the 
incus. The sound waves might then reach the foot plate through the 
vibrations of the air in the tympanic cavity and hearing be materially 
improved. 



38 



CHAPTER XXXIV. 

THE GENERAL ETIOLOGY OF DEFECTIVE HEARING. 

Defects of hearing may arise from any condition that affects the func- 
tional integrity of the conduction or the perception apparatus of the 
organ of hearing. It may be stated as a general law that the deeper 
(nearer the acoustic centre) the lesion the more profound will be the 
disturbance of hearing. 

A. Defects of Hearing Due to Lesions of the Auricle. ^This 
division of the subject may be passed by without analysis, as there is but 
slight impairment of hearing, even from the total loss of the auricle. 

B. Defects of Hearing Due to Affections of the External 
Meatus. — (a) Inspissated cerumen. (5) Furunculosis. (c) Derma- 
titis, (d) Eczema, (e) Foreign bodies, animate and inanimate. (/) 
Exostosis of the meatus, (g) Collapse of the cartilaginous meatus. 
(h) Congenital atresia of the meatus, (i) Congenital absence of the 
meatus, (j) Cholesteatomatous material. 

A glance at the foregoing analysis makes it apparent that hearing is 
diminished on account of the obstruction to the transmission of sound 
waves through the external auditory meatus and by the congenital 
absence of this canal. Congenital absence of the external auditory 
meatus is nearly always attended by absence of the middle and the 
internal ears, hence the deafness may be attributed more to the latter 
than to the former. 

Cholesteatoma within the meatus is usually concomitant with the 
same process in the middle ear and the pneumatic cells of the mastoid, 
hence the defect of hearing is largely due to the condition of the middle 
ear and the mastoid spaces. 

With these exceptions the obstructions in the meatus account for 
deafness. It should be said, however, that inspissated cerumen in the 
meatus is often a sign of middle-ear catarrh and the deafness may be 
partially due to this condition. 

Collapse of the cartilaginous meatus is usually found only in the aged, 
and the deafness may be due in part to senile changes in the middle ear 
and labyrinth. 

C. Defects of Hearing Due to Affections of the Drumhead. — (a) 
Perforation, (b) Thickening, (c) Calcareous deposits, (d) Cicatricial 
tissue, (e) Cicatricial bands extending to the ossicles and the wall of 
the middle ear. (/) Retraction, (g) Bulging or pouching, (h) Inflam- 
mation (myringitis), (i) Herpes. (_/) Traumatic rupture, (k) Frac- 
ture of the handle of the malleus. (/) Atrophy (lack of normal tension). 

It may be stated as a general acoustic law that anything which dis- 



THE GENERAL ETIOLOGY OF DEFECTIVE HEARING 595 

turbs the normal tension existing between the drumhead, the ossicles, 
and the labyrinthine fluid will result in an impairment of hearing. It 
should be noted that in nearly all of the foregoing conditions the normal 
tension is disturbed, hence the deafness. 

In a number of the catalogued drumhead lesions there are, of necessity, 
pathological changes in the middle ear which in part account for the 
deafness. For example, perforation of the drumhead is nearly always 
attended by either chronic suppuration or cholesteatoma of the middle 
ear, and possibly of the attic, the antrum, and the mastoid cells. In 
thickening, scars, cicatricial bands, calcareous deposits, retraction, and 
atrophy, middle-ear disease, usually of a chronic inflammatory nature, 
is present, and in a large measure accounts for the defective hearing. 

In simple myringitis, herpes, traumatic rupture, and fracture of the 
handle of the malleus, the middle ear is not usually involved and the 
deafness is transitory. 

D. Defects of Hearing Due to AfEections of the Middle Ear.^(a) 
Simple catarrhal otitis media. (6) Catarrh with adhesions, (c) Sclerosis 
of the mucous membrane, (d) Cholesteatoma, (e) Acute suppuration. 
(/) Chronic suppuration, (g) Ankylosis of the ossicles, (h) Ankylosis 
of the foot plate of the stapes to the oval window (fenestra of the 
vestibule), (i) Adhesive bands uniting the ossicles to each other, to 
the walls of the tympanum, and to the drumhead. (_/) Atrophic otitis 
media, (k) Anemia of the mucosa occurring with general anemia and 
debility, (l) Loss of tonicity of the stapedius and the tensor tympani 
muscles. {711) Congenital defect or absence of the middle ear. (n) 
Granulations in the middle ear. (0) Serous and mucous accumulations. 
(p) Caries of the ossicles, (q) Caries of the walls of the tympanum. 
(r) Polypus. (.?) Rarefying osteitis or spongifying of the bony capsule 
around the oval window. 

In the foregoing conditions we find the commoner causes of deafness. 
The acoustic law given in the preceding section (C), namely, that the 
condition which disturbs the normal tension between the drumhead, 
the ossicles, and the labyrinthine fluid will cause deafness, applies with 
especial force to the afi^ections in this section. All or nearly all the patho- 
logical lesions named do materially interfere with this tension, and thereby 
interfere with the transmission of the sound waves to the labyrinth. 
A study of these lesions will verify the general law enunciated at the begin- 
ning of this chapter, that as a general thing the deeper the lesion the more 
profound the deafness. For instance, a lesion affecting only the drinn- 
head does not produce as profound deafness as occurs with ankylosis 
of the foot plate of the stapes 

Sclerosis of the mucosa of the middle ear is often complicated with the 
same process in the bone beneath it. Chronic suppuration of the middle 
ear is also often attended by sclerosis (eburnation) of the bone. 

This process may extend to the mastoid or to the bony capsule of tlie 
labyrinth, and thus augment the deafness. 

The author has often seen cases in which the deafness was improved 
only after the administration of iron and arsenic. These were anemic 



596 THE EAR 

and suffering from general debility of a chronic type. Whether the 
improvement Avas due to an increased tone of the stapedius and the 
tensor tympani muscles, or to an increased tone and vital energy of the 
whole organ of hearing, would be difficult to determine. T. M. Rumbold 
inclined to the belief that the trouble was in the muscles. This may 
be true, as there may be a lack of muscular tonicity here as well as 
elsewhere in the body. It may be said with equal certainty that all the 
tissues of the body, including tliose of all parts of the auditory apparatus 
are lowered in tone and vital energy. We therefore incline to the 
opinion that the deafness due to or concurrent with general anemia, 
accompanied by seeming loss of muscular tone of the tension muscles 
of the middle ear, is prol)ably due to a lowered vitality of all the parts 
concerned in audition. 

Granulations and polypi in the middle ear not only interfere with the 
transmission of soimd waves through the middle ear, but they often 
obstruct the external meatus also. They usually signify necrosis of the 
bony walls of the tympanum and an involvement of either the cranial 
cavity, the mastoid cells, the sigmoid sinus, the jugular vein, or the 
labyrinth. 

Ankylosis of the foot plate of the stapes is a serious condition, inas- 
much as it is very difficult to permanently overcome. The deafness 
and the tinnitus are pronounced and exert a depressing influence upon 
the patient. Great care should be exercised by the otologist in giving 
the prognosis in this class of cases. He should not hold out false hope 
of ultimate recovery, but he should so couch his language that the patient 
will not entirely abandon hope. It is the physician's office to cheer as 
well as treat his patients. This is doubly true in hopeless ear cases, 
as they are often despondent to the point of suicidal mania. Fixed 
attention arouses the benumbed organs, and even though a course of 
office treatment is not advisable, the patient should be told to observe 
under what conditions he hears most clearly and to seek to adapt him- 
self to his environment. Expectant attention is thus aroused and the 
usefulness of the auditoiy apparatus is maintained at as high a level as 
is possible. In addition to the above, rest and the organic salts of iron 
should be administered. 

E. Defects of Hearing Due to Affections of the Eustachian Tube. 
— (a) Catarrh. ih) Fibrous tliickening of the mucosa. (c) Fibrous 
bands across the lumen of the tube, (d) Fibrous rings or stricture of 
the tube, {e) Lymphoid hypertrophy within the tube. (/) Hypertrophy 
of the mucosa, {g) General sclerosis of the mucosa. (Ji) Paralysis of 
the palatine muscles which regulate the patency of the mouth of the tube. 

The chief function of the Eustachian tube being to maintain the 
equilibrium of air pressure between the air in the middle ear and that 
external to it, an obstruction to the normal passage of air destroys the 
equilibrium. The normal tension of the drumhead, the ossicles, and 
the labyrinthine fluid is disturbed, and deafness and tinnitus result. 

It is not usually recognized that lymphoid hypertrophy plays a 
prominent part in Eustachian obstruction. This must be true, however. 



THE GENERAL ETIOLOGY OF DEFECTIVE HEARING 597 

as there is a considerable quantity of such tissue in the mucosa of the 
tube, especially near its pharyngeal end. The same pathological processes 
which cause hypertrophy of the pharyngeal and the faucial tonsils will 
also cause hypertrophy of the tubal lymphoid tissue. We may, then, 
speak of a tubal or " Eustachian tonsil" as a cause of Eustachian obstruc- 
tion. 

In long-continued catarrhal or suppurative inflammations of the middle 
ear, fibrous thickening or fibrous bands may form I'll the Eustachian 
tube and give rise to persistent deafness and tinnitus unless relieved by 
suitable treatment. Air not being admitted to the middle ear in sufficient 
quantity, the drumhead becomes retracted on account of rarefaction 
of the air within the middle ear, the handle of the malleus is drawn 
inward and rotated on its axis, and the chain of ossicles is forced inward 
and compress the labyrinth fluids. Perhaps a more correct statement 
would be to say that the normal tension between the drumhead and 
the labyrinth is lost, and deafness and tinnitus result. 

Tubal catarrh (salpingitis) is much more common than is generally 
supposed, and no doubt many of the so-called cases of middle-ear catarrh 
are in reality of this type. 

Since the normal patency of the tubes is controlled by the palatine 
muscles, any condition which affects their innervation or motility will 
cause defective hearing. These conditions will be considered in the 
next section. 

F. Defects of Hearing Due to Affections of the Epipharynx and 
the Fauces. — (a) Postnasal adenoids. (6) Epipharyngeal catarrh, (c) 
Polypi or other neoplasms, (d) Disease of the faucial tonsils, (e) 
Adhesions of the anterior and the posterior pillars of the fauces to the 
tonsils. (/) Suppurative inflammation of the epipharynx. (g) Paralysis 
of the palatine muscles {e.g., postdiphtheritic), {h) Infections occurring 
during the course of the exanthematous fevers. 

In this category are conditions which are fruitful sources of ear diseases 
and which are attended by impairment of hearing. All inflammatorY 
conditions which involve the mucosa about the pharyngeal orifices of the 
tubes sooner or later extend within their lumens and cause more or less 
obstruction. If the inflammation is of a suppurative type, the germs enter 
the tube and the middle ear, and may eventuate in an acute suppura- 
tive otitis media. This may become chronic, and cause permanent 
damage to the entire middle-ear apparatus. 

Postnasal adenoids are recognized as frequent antecedents of tubal 
and middle-ear catarrh and deafness. 

The discussion has often run high as to whether adenoids extended over 
tlie mouths of the Eustachian tubes. The free extremities of the lateral 
adenoid masses do, no doubt, often occlude them. Perhaps a more 
important pathological factor is that postnasal adenoids are usually at- 
tended by pronounced postnasal catarrh, which in many cases becomes 
purulent in character. This often causes obstruction of the tubes and 
thus give rise to pronounced disturbances of hearing as well as to 
structural changes in the middle ear and its appendages. 



598 THE EAR 

The etiological relationship existing between hypertrophy of the faucial 
tonsils and disease of the Eustachian tube and the middle ear has long 
been recognized, although not as fully as it should be. Their relationship 
cannot be considered apart from that of the postnasal space, however, 
as the same conditions which affect one affect the other also. Thus the 
presence of enlarged faucial tonsils is usually attended by postnasal 
adenoids. Both being lymphoid tissue, they respond to the same irri- 
tation and enlarge simultaneously. Notwithstanding this fact, there 
are some conditions of the faucial tonsils which cause tubal obstruction 
independent of any effects due to postnasal adenoids (C. R. Holmes). 

The presence of diseased or enlarged tonsils produces chronic hypere- 
mia of the mucosa of the epipharynx, and oftentimes a chronic catarrhal 
or suppurative inflammation is present. Enlarged and diseased tonsils 
do not always stand out beyond the pillars of the fauces. A normal 
tonsil can neither be seen nor felt. Many of the pathological tonsils are 
flat and lie hidden behind the anterior pillar. Pynchon has called 
them "submerged tonsils." He has also suggested that if they are 
examined "on the gag," they will bulge forward and inward and come 
into full view. When thus examined they are seen to be broad and flat 
with an irregular surface. In some cases the lacunae are filled with 
debris, epithelium, bacteria, and pus, while in others no such accumula- 
tions are to be seen. This does not prove that they are not present 
in the pockets or lacunae, as upon introducing a tonsil hook into 
them yellowish round masses may be removed. In others the masses 
are encysted, probably from inflammatory closure of the mouths of the 
lacunae. The point I wish to make is that, even though the tonsils do 
not project beyond the pillars and are not apparently much diseased, 
they may be the seat of foci of infection, irritation, and septic 
material, which give rise to chronic catarrh of the epipharynx and 
the Eustachian tubes. The material in the lacunae affords a good 
medium for the growth of bacteria, the toxins of which enter the 
lymphatic and the blood-vascular systems and cause disturbances in 
remote parts of the body. 

G. Defects of Hearing Due to Mastoid Affections. — ^As these 
conditions are secondary to and associated with pathological changes 
within the middle ear, they will not be discussed. 

H. Defects of Hearing Due to Labyrinthine Affections. — (a) 
Extra tension of the labyrinthine fluid from great retraction of the 
drumhead. (6) Inflammation of the labyrinth, {c) Congenital defects. 
(d) Hemorrhage, (e) Drugs. (/) Necrosis, (g) Tuberculous or syph- 
ilitic disease, (h) Hyperostosis or spongifying of the bony capsule of 
the labyrinth, (i) Certain neuroses cause more or less pronounced 
deafness or other disturbances of hearing. 

Increased tension of the labyrinthine fluid produces deafness. The 
increased tension is usually due to extreme retraction of the drumhead, 
whereby the foot plate of the stapes is forcibly driven inward against 
the contained fluid within the bony labyrinth. If there are no firm 
adhesions binding the drumhead and the ossicles in this position, it may 



THE GENERAL ETIOLOGY OF DEFECTIVE HEARING 599 

be readily overcome by inflating the middle ear. This at once relieves 
the deafness and the tinnitus. 

Congenital defect of the labyrinth is quite commonly found in deaf- 
mutes. It has been learned from careful functional examination that 
while they are deaf to most tones, there will be others which they can 
hear very well. (See Deaf-mutism.) 

True, Meniere's disease is thought to be due to an apoplectic form of 
hemorrhage into the labyrinth. Few postmortems have been made 
corroborative to this belief. The clinical history of the cases, however, 
is in accord with this idea. 

Syphilitic and tuberculous inflammations of the labyrinth are destruc- 
tive, not alone to the hearing, but to the tissues as well. 

The excessive administration of quinine is sometimes attended by 
pronounced deafness which may continue for several months, or even 
permanently. It is probably due to an anemia or a congestion of the 
labyrinthine membrane and the auditory nerve endings. 

Rarefying osteitis of the bony capsule of the labyrinth causes pro- 
nounced deafness, which is usually gradually progressive. It is commonly 
found in early adult life and does not yield to treatment. (See Hyper- 
ostosis of the Bony Capsule of the Labyrinth.) 



CHAPTEE XXXV. 

FOREIGN BODIES IN THE EAR. CERUMINOUS PLUGS IN 
THE MEATUS. 

Children often introduce foreign bodies into the ear for very different 
reasons from those which may be ascribed to adults. For example, 
children in their play and in the spirit of imitation will do what they 
conceive is being done by others. Their elders, in order to excite wonder- 
ment and admiration, will do sleight-of-hand performances, pretending 
to remove a knife or other object from the nose, mouth, or ears. Chil- 
dren are thus led to introduce various objects into their ears. Peas, 
beans, beads, gravel, buttons, bits of sealing-wax, chewing-gum, cherry 
pits, etc., are commonly found in the ears of children. Burnett relates 
a case of a woman from whom a bead was removed that had been intro- 
duced sixty years previously. Children are fond of the sensation of a 
smooth body, as a bead or bean, rubbed over the skin, and m this way 
they sometimes accidentally introduce foreign bodies into the external 
meatus. 

These may remain in place for a long time without causing any serious 
symptoms, and be overlooked by their parents and unnoticed bv the 
child. . 

In adults the introduction of foreign bodies into the external meatus 
is more apt to be accidental, or the result of some treatment, as the 
introduction of a bit of cotton which is allowed to remain long after 
it has served its original purpose. Bits of pencil, toothpicks, twigs, and 
straw may be introduced into the meatus during efforts to remove 
cerumen or moisture, and remam in the meatus until symptoms arise 
which cause them to seek relief from their family physician. 

Animate objects, such as roaches, fleas, flies, rosebugs, bedbugs, 
ixodLx honimos, house-fly maggots, Texas screw-worms, and other living 
parasites are the source of great agony and discomfort when they enter 
the external meatus, on account of the clawing and twisting motion 
incident to their efforts to get food or gain egress from the cavity. The 
mode and place of sleeping influence the introduction of such objects 
into the meatus, as sleeping outdoors m a hammock or upon the 
ground, thereby inviting such living insects to make their abode in this 
cavity. 

J. F. Church narrates a case in which a sheeptick had been in a stock- 
man's ear for two years. It was embedded beneath a mass of cerumen 
and l)lood, and was still living when removed. The sensation was that 
of an intolerable scratching, accompanied l)y excruciating pain and 
deafness, which would suddenly pass away. There would be intervals 



FOREIGN BODIES IN THE EAR 601 

of a month or more in which there would be no pain or discomfort 
in the ear. At times he removed blood clots admixed with cerumen. 
When he came imder the observation of Dr. Church the pain was 
severe, and had been for about four days, and extended to the mastoid 
region. There was a feeling of numbness over the corresponding side 
of the face. The meatus was filled with cerumen and epithelium, 
which was removed with a spud and a syringe. This being done, the 
deeper portion of the meatus was exposed to view, and a moving 
body was seen, which presented the appearance of a perforation in the 
drumhead, as he thought, with slender maggots protruding through it. 

The Texas screw-worm fly, or Compsomyia (Lucilla) macellaria, has 
been thought to be of Mexican or South American origin, although Dr. 
Williston, of Yale College, writes that "It grows especially from Canada 
to Patagonia." Its chief centre in the United States, however, has been 
in Texas, hence its name. 

Its ravages among cattle are common, and often occasion heavy finan- 
cial loss by the destruction of its victims. It more rarely invades the 
human family, but has been known to cause death in a number of 
instances. Its favorite point of attack in the human is the ear or 
the nose. This is easily understood when it is known that the insect 
is attracted by foul-smelling odors. Those, therefore, affected with 
ozena or chronic otorrhoea are especially Hable to be invaded. The 
worm in the act of invading the tissues performs a sawing motion, and 
can penetrate bone. Mackenzie reports cases in which the cranial 
cavity was penetrated by them, causing death from meningitis. 



FOREIGN BODIES IN THE EAR. 

Treatment.^ — It is important in this connection that a caution be 
given as to the great harm that may be done by unwarranted, unskilful, 
or untimely efforts to remove foreign bodies from the external meatus. 
It should be remembered that foreign bodies, especially inanimate 
ones, can do little or no harm so long as they are left undisturbed 
in the meatus. This, of course, is not true for an indefinite period 
of time, but it is true in the sense that there is no need of haste on the 
part of the attending surgeon. More harm has been done to patients 
by the efi'orts to remove foreign bodies than has ever been produced 
by the presence of these liodies by themselves in the meatus. If a 
foreign body is smooth and is causing no pain or discomfort, there is 
certainly no occasion for its hasty removal; if it is a rough one, and is 
causing considerable pain and discomfort, tiiere is more excuse for its 
immediate removal; but even then it may be much wiser to first allay 
the irritation and swelling, after which it may be removed with comjiara- 
tive ease with either the syringe, snare, or forceps. 

I liave seen cases in which the meatus was swollen and I'ed from tlie 
unskilled attempts of members of the family to remove an object. While 
thus swollen it was impossible for me to remove tlie foreign body with- 



602 THE EAR 

out great pain. In such instances I have first used antiphlogistic reme- 
dies and soothing appHcations for a few days, after which it was compar- 
atively easy to remove the foreign body without any great difficulty or 
pain to the patient. If an insect or other live body gains entrance to 
the meatus, the first step to be taken is to render it lifeless, after which its 
removal can usually be efi'ected with a syringe. 

Having thrown out this warning against meddlesome or unintelligent 
attempts to remove inanimate foreign bodies, we will discuss the best 
methods of procedure for their removal. 

1. First inspect the meatus in order to determine whether or not a 
foreign body is present, and if present, its probable nature. This is 
important, as the method of procedure for its removal will depend 
largely upon the character of the body present. 

2. Notice whether irritation or inflammation of the parts is present, 
and whether it is probable that the body will do harm by remaining a 
few days or hours longer; and also as to whether it is probable that if 
immediate steps for its removal are taken, the effort would be rewarded 
by success. If the parts are swollen and inflamed to such an extent 
as to make it impracticable to remove it at once, it is better to wait until 
the swelling and inflammation are reduced by the use of hot, soothing 
lotions, such as boric acid solution, and by the application of leeches to 
the tragus. After a few hours, or at the most a few days, the swelling 
and painful condition will have subsided, thereby rendering the removal 
of the offending object a matter of comparative ease and with little 
discomfort to the patient. 

3. Syringing should first be tried, as the stream of water may be 
forced into the meatus beyond the foreign body, and forced from the 
external auditory meatus. The position of the head should be con- 
sidered in this and other methods of procedure, as the force of gravity 
will oftentimes materially aid in the removal of the object. The head 
should, therefore, be inclined toward the affected ear. Zaufal found, in 
109 cases of foreign bodies in the external meatus, that he could remove 
92 of them with the syringe, thereby demonstrating that nearly 90 per 
cent, of the foreign bodies in the meatus may be removed by this method. 
I fear that in the average practitioner's experience 90 per cent, of the 
removals have been attempted with either forceps or the so-called "ear 
hook;" whereas the 90 per cent, of successful efforts should have been 
made with a syringe, while in the other 10 per cent, it may have been 
proper to resort to the forceps and ear hook. 

4. The agglutination method was recommended by Riverias in 1674, 
and by Celsus in 1806, being revived by Lowenberg in 1872. It con- 
sists in applying some heavy glue to the end of a piece of tape or a 
camel's-hair brush, which is then applied to the foreign body in the ex- 
ternal meatus and left there until the glue becomes so firmly fixed as to 
bring the foreign body with it when traction is exerted upon it. This is 
probably one of the best methods, for most of the cases after syringing 
has failed. It is to be recommended on account of the absence of in- 
strumentation, whereby the meatus is so often seriously injured. 



FOREIGN BODIES IN THE EAR 603 

A strip of adhesive plaster may be introduced into the meatus, appKed 
to the foreign body and heated by focusing the rays of hght upon it 
with a convex lens. This softens the adhesive material and allows it 
to become fastened to the foreign body, after which it may be removed 
by traction upon the adhesive strip. 

The agglutination method is not used as often as it should be, as most 
physicians seem to think that a pair of forceps or the foreign body hook, 
which usually accompanies the pocket-case purchased upon graduation, 
are the instruments par excellence for this purpose. 

5. The foreign body hook is, perhaps, less harmful in the hands of 
an inexperienced operator than the forceps, and is, therefore, to be 
recommended as a better instrument for the removal of foreign bodies 
from the external meatus. It should be so introduced as to allow the short 
hook to pass inward with its side against the wall of the meatus until it 
passes beyond the foreign body, when it should be rotated so as to bring 
the hook back of the foreign body. Slight traction should then be made 
upon it, with a view of dislodging the foreign body from its position in 
the meatus. If it fails to do this, it should be withdrawn and re-intro- 
duced in another position, hoping thereby to find a point at which the 
body may be loosened. If the foreign body has passed beyond the 
isthmus of the meatus and lodged in the recess formed by the membrana 
tympani and the floor of the meatus, the hook should be introduced above 
the foreign body, as there is greater space at this point for the outward 
movement of the impacted mass. The convexity of the floor of the 
external meatus forms a favorable fulcrum upon which the lower 
portion of the foreign body rests, while the upper portion makes the 
outward excursion. If will be necessary, however, in some cases to 
introduce the hook either posteriorly or anteriorly in order to slowly 
dislodge the mass from its fixed position. After this has been done the 
hook should be introduced above the mass, completely dislodging it from 
its point of impaction. Its removal through the cartilaginous meatus may 
then be accomplished with ease and little discomfort to the patient. 

6. Various foreign body ear forceps have been devised and placed 
upon the market, none of which serve a very useful purpose. Young- 
practitioners have great satisfaction in the thought that they have a full 
equipment at their command for the removal of foreign bodies from 
the ear. Beyond the satisfaction they thus afford, the instruments are 
of little value. It is with such instruments that untold harm and irre- 
parable damage have been done, and not a few lives have been sacri- 
ficed to the enthusiasm of their owners. The foreign body has, in many 
instances, been forced through the drumhead into the middle ear, 
where the physician has left it, only to be discovered at a later period 
during a mastoid operation. 

After a time its presence in the middle ear gives rise to necrosis and 
serious infection, followed by intracranial complications, such as abscess, 
meningitis, or sinus tiironibosis, thrombosis of the jugular vein, laby- 
rinthine necrosis, or traiisiiiissioii of infective thrombi to tlie hnigs, the 
spleen, or the kidneys. 



604 



THE EAR 



Having thus briefly, but pointedly, suggested the dangers attending 
the use of foreign-body forceps, it may be said that they have a useful 
place, limited though it be, in the armamentarium of the physician. 

The cautions given above are not for the purpose of discouraging the 
practitioner from using the foreign body forceps, but are intended to lead 
him to use them with great circumspection after having tried all other 
means for the removal of the foreign body. Those devised by Dr. Samuel 
Sexton are, perhaps, the best upon the market (Fig. 344). They are so 
constructed that the toothed tips may be introduced at the sides of the 
body, while the blades remain practically parallel with the walls of the 
external meatus; this is a point of no small importance when we remem- 
ber that most forceps for this purpose are so constructed that when the 
blades are spread apart the tips are at such an angle as to be easily forced 
into the meatal w^alls as they are pushed inward beyond the foreign body. 
Whatever instruments may be used, great care and delicacy of manipu- 
lation should be exercised, so as to avoid serious laceration of the meatus. 




Sexton's foreign-body forceps. 



If the foreign body is removed the laceration will be of small moment, 
as it can be properly treated and quickly healed; if, however, the efforts 
to remove the foreign body are unsuccessful, the laceration may become 
a very serious complication, as the parts cannot, for obvious reasons, 
be properly treated. Swelling, infection, and inflammation may take 
place, which will still further interfere with the removal of the foreign 
body. Great discomfort results, and the condition is a serious menace 
to the well-being of the patient. 

7. Postauricidnr incision for the removal of foreign bodies is a very 
ancient method of procedure, as Paul of Aegina suggested its use. 
Von Troltsch, in his text-book on Surgical Diseases of the Ear, sug- 
gested that in infants the incision is most effective when made above 
the auricle in the squamous region, as this position is depressed at that 
age, thus admitting of easy access to the meatus without injuring the 
postauricular artery. He thinks the injury to the artery should not be 



ANIMATED FOREIGN BODIES IN THE EAR 605 

done needlessly, as it is an important source of nutrition to the auricle. 
With our more improved methods of surgery and asepsis, we do not now 
fear an injury to this artery, and would not, therefore, make the incision 
above the auricle with this object in view. The incision in this posi- 
tion is, however, undoubtedly best adapted for the removal of foreign 
bodies which cannot otherwise be removed from the meatus of an infant 
on account of the oblique angle it forms with the squamous plate. 
The roof of the osseous meatus is gradually formed by the development 
of the squamous bone, and extends inward at an obtuse angle, thus 
affording a favorable field for the introduction of instruments for the 
removal of foreign bodies. In adults, von Troltsch suggests that the 
incision should be made inferior to the meatus, as its roof is now at right 
angles to the squamous plate. 

With the antiseptic and aseptic methods now in vogue there should be 
little hesitancy in making a free incision in much the same manner as 
described for mastoid operations. The wound can be closed at once, 
union by first intention taking place. The cartilaginous meatus should 
be separated from the bone as in the mastoid operation and lifted from 
its position. The foreign body is thus fully exposed to view on all sides, 
the meatus is shortened and enlarged, and instrumentation for its re- 
moval becomes comparatively easy. The patient should be under the 
influence of a general anesthetic. A portion of the osseous meatus 
should be chiselled away, if necessary, in order to facilitate the removal 
of the foreign body. 

Urbantschitsch reports a case of an oat husk which entered the 
Eustachian tube while the patient was chewing an ear of grain. It 
passed through the tube into the middle ear, and thence into the external 
meatus. 

ANIMATED FOREIGN BODIES IN THE EAR. 

Treatment. — Great concern is usually occasioned by the entrance 
of an insect or other animate body in the external meatus, on account 
of the clawing and scratching and penetrating movements attending its 
presence. Great noises of the most distressing and horrifying character 
are sometimes present, due no doubt to the clawing and scratching 
against the drumhead. On account of the great mental disturbance 
of the patient, the physician should have well-formulated ideas as 
to the proper methods of procedure for the removal of the insect, as 
lie will otherwise be led to resort to methods in his haste and anxiety 
which will ])i-obal)ly be unsuccessful and will only add to the pain and 
discomfort of the patient. I would, therefore, make the following 
suggestions : 

(a) Avoid the use of instruments. It lias been found by experiejice 
that animate objects are not readily removed by the use of forceps or 
other instruments. They have the power of clinging tenaciously (o tlir 
skin of the meatus with little hooklets in the case of maggols, mid wilh 
the feet in a case of fulIy-fk>veloped insects. 



606 THE EAR 

(6) Drown the insect. This can usually be done with oil; if oil is not 
at your command, water may be used instead. If maggots are within 
the meatus, a 50 per cent, solution of chloroform should be used for this 
purpose, as oil or water seems to have little power to cause their death. 

(c) If for any reason it is desired to immediately remove them without 
waiting to render them lifeless, the syringe should be resorted to, as in 
this way they may sometimes be removed with great ease. On the other 
hand, the method is oftentimes not successful until they have l)een ren- 
dered lifeless by drowning in the water. If maggots are present, the 
fumes of chloroform blown into the ear from the bowl of a pipe will 
almost instantly render them lifeless. Solutions of chloroform may also 
be dropped into the ear for this purpose with more certain results. 
After they are rendered lifeless the insects or larvae are easily removed 
with the syringe, and it will rarely be necessary to resort to the use of 
forceps. Should it become necessary, however, to resOrt to their use, 
they should be used with great caution, as otherwise a very serious in- 
jury to the meatus and driunhead may be inflicted. The use of chlori- 
nated water is of special value in rendering them lifeless, and especially 
the larvse. It is not, however, as efficacious as chloroform. 

{d) The agglutinative method may be used for the removal of dead 
insects from the ear, as described under Foreign Bodies in the Ear. 
Forceps may be used likewise, but are only mentioned in this connection 
for the purpose of condemning their use, except in very rare instances. 



FOREIGN BODIES IN THE EUSTACHIAN TUBE AND MIDDLE EAR. 

Mayer^ reports three cases of foreign bodies in the Eustachian tube: 
one, a grain of corn, was in the bony portion of the tube, while the others 
were in the cartilaginous or faucial end. They may enter the tube 
either through the middle ear or the epiphar}Tix. If there is a perfora- 
tion in the drumhead, a small grain or other substance may enter the 
middle ear through it, and thence pass to the Eustachian tube. Foreign 
bodies which are unskilfully or roughly handled in the effort to remove 
them from the external auditory meatus may thus be driven into the 
middle ear, from whence they may gain entrance into the Eustachian 
tube. 

The use of Eustachian bougies has, in the past, been a fruitful source 
of foreign bodies in the tubes from accidental breaking while being used. 
Formerly the bougies were armed with feathers, cotton, or hair, for the 
introduction of medicaments, and were, consequently, more liable to be 
broken in the tube. Better and smoother mstruments are now used, 
hence the accident occurs less frequently. 

Voltolini has recommended the galvanocautery for the removal of 
firmly embedded organic substances, as beans, etc., from the meatus and 
the middle ear. At various sittings small portions are thus destroyed, 

' Monatsschrift f. Ohrenheilkunde, Jahrg. iv, Nr. 1. 



CERUMINOUS PLUGS '' 607 

until the whole is finally disintegrated and removed. This method of 
procedure should be attempted with great caution, as there is considerable 
danger of exciting inflammation of the contiguous parts. 

If the foreign body is so deeply and firmly embedded in the middle 
ear as to render it impossible to remove it by simple and direct methods, 
the postauricular incision, such as is described under mastoid opera- 
tions, should be made, and, if necessary, a portion of the bone of the 
meatus may be chiselled away. Having thus exposed it, an attempt 
should be made to remove it with a stream of water. Should this fail, 
forceps may be used. 

Foreign bodies in the cartilaginous or faucial end of the Eustachian 
tube may sometimes be seen with a postrhinoscopic mirror as they pro- 
trude from the mouth of the tube. In such cases it is often possible to 
seize the protruding end with a pair of curved forceps introduced through 
the mouth and thus remove it. If this cannot be done, the drumhead 
may be perforated by means of a V-shaped incision, if a perforation does 
not already exist, and the air forced into the middle ear by means of a 
Politzer bag or other compressed-air apparatus with a suitable tip, 
which is applied at the external meatus. In this way the current of air 
may be made to enter the Eustachian tube and force the foreign body 
from the pharyngeal orifice. 



CERUMINOUS PLUGS. 

Cerumen is the product of the ceruminous glands, located chiefly in 
the cartilaginous portion of the external auditory canal. A few glands 
are also present at the commencement of the osseous portion of the canal. 
The cerumen is normally thrown off by the movements of the mandible 
(inferior maxilla) and by the exfoliation of the epidermis lining the canal. 
When, however, from any cause the secretion becomes excessive in quan- 
tity, more tenacious in quality, or its discharge is mechanically obstructed, 
ceruminous plugs form in the canal and give rise to more or less dis- 
turbance of hearing. 

Etiology. — The etiology may be studied under (a) diseases of the 
canal and middle ear; (h) obstructive lesions of the canal; (c) modifica- 
tions in the character of the ceruminous secretion ; (d) foreign bodies in 
the canal; and (e) improper methods of washing the ear. 

(a) The diseases of the canal and middle ear which cause ceruminous 
plugs may be subdivided into hyperemia of the skin of the canal, dift'use 
and circumscribed eczema, and suppurative otitis media. 

(6) The obstructive lesions of the canal are congenital, as a tortuous 
canal, and acriuired, as meml)ranous })ands or rings from inflammatory 
processes, and hyperostosis and exostosis of the canal. 

(c) Modifications in the character of the cerumen, as an increased 
adhesiveness and the admixture of epithelium aufl liairs cause the re- 
tention of the cerumen. 

{d) Foreign bodies in the oxtornnl canal form llio nurlei of ceruminous 



608 THE EAR 

plugs. Tliey may be solid substances, as beads, small stones, etc., or 
they may consist of dust, sand, or other finely divided particles. 

(e) Improper methods of washing the ears are often responsible for the 
presence of ceruminous accumulations in the canal. Irritating soap-suds 
is introduced, the epidermis macerated in it, and the glands overstimu- 
lated. A mild dermatitis results. On top of all this the corner of a 
towel or a washrag is twisted and screwed into the meatus, causing still 
further irritation, and oftentimes pushing the cerumen into the osseous 
])ortion of the meatus, where it remains, forming a nucleus for still more 
extensive accumulations. 

Symptoms. — The symptoms vary according to the degree of occlu- 
sion, the ]x)sition of the plug, the amount of secondary irritation and 
infianunation, and the preexisting or associated lesions in the middle ear 
and labyrinth. 

If the occlusion of the canal is incomplete in an ear w^iich is otherwise 
normal, there will be but little impairment of hearing; if, on the other 
hand, the canal is entirely closed, there is marked diminution of hearing. 
If the plug is dislodged into the fundus of the canal against the drum 
membrane, the disturbance of hearing and the discomfort are much 
greater. In some cases the plug is accompanied by severe inflammatory 
reaction of the tissue immediately contiguous to it, which adds to the 
discomfort and the impairment of hearing. Reflex pains in the mastoid 
region are not uncommon in this condition. 

If suppurative inflammation of the middle ear and the mastoid cells 
is associated with the ceruminous plug, the symptoms are modified 
accordingly; that is, there is a commingling of the symptoms of the two 
conditions. 

Pain is a symptom which is present only when the cerumen is hard 
and exerts pressure on the inflamed walls of the canal. 

In general, it may be said that the patient complains of a feeling of 
fulness in the ears and the head, and of dizziness, vomiting, headache, 
stupor, facial paralysis, trigeminal neuralgia, brain irritation, eclampsia, 
blepharospasm, pain, etc. One or several of these symptoms may be 
present at the same time. 

The hearing may suddenly change from good to bad, or vice versa. 
When the drumhead is perforated the plug may improve the hearing by 
acting as an artificial membrane. 

Diagnosis. — The diagnosis is made by inspecting the canal, either 
with a sjx'culum or by simply lifting the auricle upward and backward. 
The plug appears as a yellow or brownish mass of greasy or granular 
material, which, upon probing, proves to be either soft, semisolid, waxy, 
solid, or hard as stone. 

It may be mistaken for cholesteatoma, dried blood, a foreign body, 
cotton stained with secretion, etc. In some cases there is an excessive 
exfoliation of epidermis, which, becoming admixed with hairs and 
cerumen, lodges in the canal, thereby causing its occlusion. In those 
cases we have to deal with a pathological desquamation of epidermis 
rather than with a hypersecretion of cerumen. 



CERUMINOUS PLUGS 609 

Prognosis. — When there is sudden loss or diminution of hearing 
following the introduction of water or other liquids into the meatus, 
the prognosis as to hearing is good, as the disturbance is probably due 
to the swelling of the plug, which obstructs the canal. Cases com- 
plicated by either adhesive otitis or labyrinthine affections are not 
greatly relieved by the removal of the cerumen. 

If we apply the tuning fork to the vertex, as in Weber's test, and the 
sound lateralizes to the obstructed ear, we gain no information, as the 
lateralization might be due to either middle-ear disease or to the plug. 
If, however, it lateralizes to the unobstructed ear, we may suspect laby- 
rinthine involvement on the obstructed side. 

Treatment. — The only form of treatment to be recommended is the 
removal of the cerumen by forcible injections of warm water with a 
syringe. If the plug has a moist appearance, or is soft to the probe, the 
injections may be made at once; whereas if it is hard and lustreless, 
it should first be moistened by instilling a few drops of a solution of 
bicarbonate of soda and glycerin in water; this should be repeated 
three or four times daily for about three days. The addition of the 
glycerin is advantageous on account of its hygroscopic properties, 
which maintains the plug in a moist state between the instillations. 

In rare instances the use of a round-ended probe may become neces- 
sary on account of the firm adhesion of the cerumen to the meatus. 
Persistent injections will ordinarily remove all secretions. Dizziness, 
or even vomiting, is sometimes induced by the force of the stream, the 
intralaljyrinthine pressure being disturbed by the inward movement of 
the foot plate of the stapes. 

Keratosis Obturans, or Epithelial Plugs in the External Meatus. — In 1874 
Wreden described this condition, calling it "keratosis obturans." It is 
caused by a chronic desquamative dermatitis, in which the epithelium 
is gradually thrown off and accumulated layer by layer in the fundus of 
the canal. More or less deafness results, according to the degree of 
occlusion and the proximity to the drumhead. It is often mistaken for 
cerumen, as its layers are admixed wnth and its surface covered by 
it. A careful macroscopic or microscopic examination will clear the 
diagnosis. Mr. Richard Lake advances the theory that it is caused 
by a dry, scaly eczema, which is excited by the ceruminous plug, while 
Burnett suggests that it is due to an excoriation and slow exudation of 
dermoid cells, brought on by rough and clumsy attempts to clean the ear. 

Pain in the meatus is the most constant symptom. In rare cases it 
radiates around the ear and over the temporal region. 

After syringing the ear the plug becomes whitish or grayish in color, 
on account of the removal of the outer layer of cerumen, which is readily 
soluble in water. It is firm and dense and more or less adherent to the 
walls of the meatus. After its removal, if placed in water, it does not 
soften and break up as cerumen does under like conditions. Its layers 
resemble sodden white parchment. 

Treatment. — Before j)roceeding to remove the ])lug with the syringe, 
it should hrst i)e gently separated from the walls of the meatus with a 
39 



610 THE EAR 

flat applicator. This allows the stream of water to pass around and 
behind it, and facilitates its expulsion. If, however, it does not readily 
come away, it should be removed piece by piece with a probe or forceps, 
one hour often being required for its accomplishment. Children do 
not calmly submit to the procedure, as it is somewhat painful; an anes- 
thetic should, therefore, be given. Recurrences may be expected; 
hence, frequent examination and treatments may be necessary. 



CHAPTEK XXXVI. 

MALFORMATIONS AND NEOPLASMS OF THE AURICLE. 
MALFORMATIONS. 

Malformations of the auricle are of importance chiefly from a cos- 
metic point of view. The auricle plays such a small part in the function 
of audition that its entire absence does not materially influence the 
acuity of hearing. If, however, the auricle is so shaped as to occlude 
the meatus, it may materially interfere with the transmission of the sound 
waves and thus impair hearing. In most cases, however, when there 
is a. very marked defect there is also defective formation of the external 
auditory meatus, the middle ear, and the labyrinth; hence, diminution in 
hearing is usually due to other conditions than the changes in the auricle. 
As stated in the beginning, malformations of the auricle are of interest 
chiefly from a cosmetic standpoint. 

The malformations may assume a great variety of forms, ranging 
from a plurality of the auricle to its entire absence. Between these two 
extremes the auricle may be deformed to a slight degree, or it may be 
overdeveloped or misshapen in almost every conceivable way. It may 
be either arrested or overdeveloped. One part may be overdeveloped, 
while in another the development is arrested. It is not uncommon to 
see in any large company of people ears which project very markedly 
from the head, and which often give rise, especially among school- 
children, to their possessors being called "yellow kids." The term 
"lop ear" is often applied to the same condition. 

The defect may be either congenital or acquired. If congenital, it is 
due to a lack of closure of the branchial clefts and to a disproportionate 
development of one or more of the six tubercles or centres of develop- 
ment. It may be unilateral or bilateral, usually the former. The 
bones of the face upon the side affected are usually also arrested in their 
development. 

Stahl, in 1859, called attention to the fact that deformity of the auric- 
ular cartilage might be regarded as an indication of arrest of develop- 
ment of the skull, and that it bore a relationship to the development of 
the skull. Defective formation may consist of the entire absence of the 
auricular cartilage, although it is probable that in nearly every instance, 
if a careful examination were made, a small cartilaginous growth would be 
founrl beneath the skin. The arrest may take on the form of a simple 
slirivelling of the whole auricle, or of a portion of it. On the other liand, 
it may consist of an excessive development of one part and a diminislied 
development of another; or it may assume any irregular type of develop- 



612 THE EAR 

ment, as a twisted slicll, or it may be hooked, cone-shaped, fissured, or 
cauliflower-like in form. 

Sometimes the upper portion of the auricle is turned downward 
from above and compressed against the middle portion, as is seen in 
the old statues of Pan (Politzer); or it may have deep indentations or 
horizontal fissures and in rare instances, it may be spindle-shaped. 
The tragus may be twisted inward, so as to close the meatus, or there may 
be an absence of the auricle with the exception of the lobule. This 
may be free or adherent to the adjacent skin. The meatus was present 
in a case of this kind reported by Schwartze. It opened beneath the 
loliule and led upward and inward to the drumhead. 

The auricular appendages or supernumerary auricles, according to 
Virchow, consist of reticidar cartilage, subcutaneous cellular tissue, and 
skin. They are usually located in front of the tragus, although they 
may be on the lobule, the side of the neck, or the shoulders. Saissy, in 
1S29, advanced the theory that malposition of the auricle from an im- 
properly placed head-dress invariably led to arrest of development. He 
says: "Boys often wear their hats so low upon the head as to either push 
the ear outward and cause it to project from the head, or to compress it 
against the head and cause it to assume too close a position. The latter 
often occurs in females from confining the ears too closely with the head- 
dress. To remove the deformity, it is only necessary to correct the habit." 

jNIaschziker, in 1S64, in his text-book on The Ear and Its Diseases 
and Their Treatment, states that ears are placed in malposition by too 
tightly drawn caps on children. 

I have known mothers to bandage the ears of their little ones to bring 
them more closely to the head, even when their fathers had widely pro- 
truding auricles, and the children had evidently inherited the physical 
trait. Thus the scientific tradition still holds popular credence, and 
many a little child is made to suffer in consequence. 

Saissy's views on the subject of imperforation of the external meatus 
were more nearly correct, as he regarded it as usually associated with a 
congenital and irremediable defect of the middle and the internal ear. 
The etiology of auricular ear deformity is to be found in the disordered 
development of the organ of hearing. There is insufficient closure of 
the upper two branchial clefts, which arrests or accelerates develop- 
ment of one or more of the six tubercles or centres of development, as 
shown by Minot, Talbot, and others. 

Classification. — Auricular deformities may be classed as follows: 

(a) Entire absence of the auricle. 

(b) Overdevelopment of the auricle (macro tia). 

(c) Plurality of the auricle (polyotia, supernumerary). 

(d) Arrested development of the auricle (microtia, shrivelled). 

(e) Distortions of the auricle (cat-ears — as in the statues of Pan — 
shell-, scroll-, hook-, spindle-, cone-, fissure-, and cauliflower-like for- 
mations). 

(/) Fistida in avris congenita is a remnant of the first branchial cleft, 
and was first described by Heysinger in 1870. It opens in front of the 



MALFORMATIONS 



613 



ear, either above or below the tragus, and is a bhnd canal filled with 
creamy secretion admixed with pus. When its mouth becomes closed 
the secretion accumulates within the canal, which may be felt as hard 
nodules beneath the skin. Fistula auris congenita are of slight impor- 
tance, and may be healed by laying them open with a knife and remov- 
ing the epithelial lining and bringing the parts together again, after 
which they unite by first intention, and thus obliterate the canal. Mild 
caustic applications may be applied within the canal to excite inflam- 
mation and adhesions for the purpose of closing the canals. 

Fig. 345 illustrates one of my cases of microtia. The drawing is 
from a plaster cast of the ear. The young man is healthy and has a 
normal ear upon the opposite side. The cartilages of the fragmentary 
auricle are not attached to the skull in any 
way except by the skin. There is an en- -^^°- ^,*^ 

tire absence of the external auditory meatus, 
and bone conduction is nil upon this side. 
He came to me to have the ear "opened up," 
if I thought it advisable. iVs there was no 
bony meatus, and the autopsies on similar 
cases have shown the middle-ear apparatus 
and labyrinth to be absent or quite rudi- 
mentary,^! advised him to leave the ear as 
it was. 

Treatment. — Macrotia. — Figs. 346 and 
347 illustrate one of my cases of macrotia. 
The latter case was referred to me by G. F. 
Suker, for the reduction of the lop-ear. The 
boy was eleven years old, and presented 
numerous stigmata of degeneracy. His 
schoolmates called him the "yellow kid." 
It was, therefore, decided to overcome the 
defect by operating upon the auricles. This 
was done under general anesthesia. 

The skin on the posterior surface of each 
auricle was incised with a knife, the line of incision extending in a 
curve from within one-fourth inch of the superior attachment of the 
auricle to within one-half inch of its inferior attachment. A second 
incision was begun at the upper point and extended backward and 
downward over the mastoid process one-half inch posterior to the 
attachment of the auricle, and made to join the inferior end of the 
auricular incision (Fig. 346). An ellipse or segment of skin not unlike a 
segment of orange peel was thus outlined. This was dissected from the 
auricle and the mastoid process. The second step of the operation con- 
sisted in cutting through the cartilage of the auricle, following the line 
of the auricular skin incision. The cartilage was then severed at the 
auriculomastoid junction, care being exercised to avoid cutting through 
the skin on the anterior surface of the auricle. The cartilage was next 
carefully separated from the anterior skin of the auricle (a). 




Author's case of microtia. The 
external auditory meatus, middle 
ear, and labyrinth are absent. 



614 



THE EAR 



The third step of the operation consisted in closing the wound (Fig. 
347). This was done in such a way as to bring the auricle close to the 
head, as the operation was done principally for this purpose. In order 
to do this four deep stitches with silkworm-gut were taken, so as to in- 
clude the auricular skin, the auricular cartilage, the fibrous tissue over 
the mastoid, and the mastoid skin. These were drami firmly together 
and secured. Ochsner's continuous horsehair suture was then used to 
bring the edges of the skin together. 





Fig. 346. — A, operation for macrotia^or' lop-ear. An elliptical piece of skin (a b) has been 
removed from the posterior wall of the auricle and mastoid process, a, the area of cartilage 
to be removed from the concha of the auricle. 

Fig. 347. — The operation for macrotia, or large projecting auricle. B, the sutured incision at 
the close of the operation; C, the cartilage removed from the concha of the auricle; D, the skin 
removed from the posterior aspect of the auricle and the mastoid process. 

The superficial sutures were removed on the sixth day and the deep 
stitches on the ninth day. 

The results of the operation were excellent. Before the operation 
the auricles at Darwin's tubercle were 3.5 cm. from the side of the head, 
and after the operation they were 1.5 cm. distant. Three months after 
the operation they were 1.25 cm. from the head. 



NEOPLASMS OF THE EXTERNAL EAR. 



Othematoma. — Definition. — This is a disease of the auricle charac- 
terized by an effusion of blood between the perichondrium and the 
cartilage. It may occur spontaneously or from direct violence. When 



NEOPLASMS OF THE EXTERNAL EAR 615 

it occurs spontaneously it is probably due to degenerative changes in 
the bloodvessels of the fibrous bands which traverse the cartilage of 
the auricle. It is also probable that degenerative changes occur in the 
fibrous tissue. 

Etiology. — Dementia seems to have a close relationship to the disease 
as it is commonly found in the insane. Inhumane treatment of this 
class of patients has been so often charged, and it is more than probable 
that traumatism accounts for it among them to a large measure. This 
is rendered more than probable by the fact that most of the cases have 
involvement of the left ear, the blow from the right hand of the attend- 
ant striking this ear. It must not be presumed, however, that this is 
the only cause, as the degenerative changes above referred to would 
be expected in this class of patients. The famous prizefighter, 
Battling Nelson, has othematoma, caused by numerous blows upon 
the ear in a series of boxing matches in which he did not have the 
opportunity of applying hot water. 

The condition is common among the wrestlers of Japan, traumatism 
being the probable cause. 

Symptoms. — The tumor forms quickly, thus distinguishing it from 
perichondritis, angioma, and other neoplasms. The rapid development 
after an injury is quite characteristic. Its color is bluish, and it is 
rounded and soft to the touch. It does not have the distinct fluctuation 
common to fluid sacs beneath the skin, but offers a doughy resistance. If 
it is due to traumatism it is usually quite large, often involving the whole 
or the upper portion of the auricle; whereas if it is idiopathic it is often 
quite circumscribed, being limited to a nodule in the concha or other 
depression of the auricle. It is most common on the anterior or concave 
surface of the auricle (Fig. 348). 

Pain is present in the traumatic variety, but is absent in the idiopathic. 
The tumor is opaque by transmitted light, whereas that of perichon- 
dritis is transparent. If the auditory meatus is occluded by the swelling, 
deafness and tinnitus are present. It should be borne in mind that the 
deafness may be due to the rupture of the ear drum from concussion. 
In the case of Battling Nelson, the hematoma became organized and 
caused permanent deformity. 

Diagnosis. — The diagnosis is based upon the rapid development of the 
growth after an injury, the opaqueness by transmitted light, and the 
absence of febrile symptoms. In the spontaneous variety the rapid 
development of the tumor mass is quite characteristic. 

Prognosis. — The traumatic variety ends by resolution more readily 
than the idiopathic variety, except when there is extensive damage to the 
cartilage. If there are no reactive symptoms and the swelling dimin- 
ishes in size, the prognosis is favorable. Violent inflammatory symp- 
toms, on the other hand, necessitate opening the tumor, thus rendering 
the prognosis more unfavorable. Some cases recover without visible 
deformity, while others recover with great shrinkage or other deformity 
of the cartilage. 

Treatment. - Tlic treatnieiit sliould be symj)t()inati(' and niodified to 
corresj)()ii(l witli tlic jx'ciiliar pathology of the case. If, for instance, tlic 



616 



THE EAR 



othematoma is due to degenerative changes in the bloodvessels and the 
connective tissue or the cartilage of the auricle, it would be folly to apply 
massage to promote absorption, as such manipulation would probably 
j)rovoke more hemorrhage. Such a procedure, if tried at all, should be 
deferred until regeneration has closed the interior wounds. Pressure 
bandages are also contraindicated for the same reasons. The applica- 
tion of ice-bags or a Leiter coil may exert a favorable influence in 
])reventing passive inflammatory swelling; and if it is already present, 
the cold rtxluces it somewhat. The application of heat is better treat- 
ment, as it promotes regeneration. Cooling lotions locally and cathartics 
may also be used with some advantage. The inflammatory type should 
be incised and antiseptic dressings applied. 




Othematoma with ossification following a liist cry of dementia and traumatism. 
(Dr. G. McAuliff's case.) 



Politzer recommends the puncture of the tumor in the early stage of 
its development. If this is not followed by relief it is better to open it 
thoroughly by free incision, after which the contents can be removed 
and the cavity packed with iodoform gauze. 

Angioma. — Symptoms .^ — The bright-red or lurid patches which are 
not elevated ab(jve the surface of the skin are not included in this group 
of tumors. Angioma as used in this connection refers to the cavernous 
tmnors, which are bluish red in color and are made up of a series of 
venous sinuses or cavities of various sizes and shapes. They are often 
separated from each other by perforated fibrous septa, thus afi^ording 
free intercommunication of their blood contents. 

They may appear in the auricle, in the meatus, or in both. They 
may be either primary or secondary extensions from adjacent struc- 
tures. They vary in size, rarely growing larger than a small hen's egg. 
They are irregular in shape. Pulsation is occasionally present. Angi- 



NEOPLASMS OF THE EXTERNAL EAR 617 

oma is sometimes congenital, while in other cases it develops after 
trauma or after the gradual dilatation of the bloodvessels of the simple 
angioma, the bright-red or lurid patches referred to in the preceding 
paragraph. Instances are on record of an angioma appearing after 
the auricle had been frozen. 

The presence of pain depends chiefly upon the rapidity with which 
they grow. If of rapid development and large size, the pain is consid- 
erable. Troublesome pulsation is another characteristic of angioma of 
rapid growth. 

Deafness is present in those cases in which the meatus is occluded. 
Reflex cough may also be present when the meatus is involved. 

Diagnosis. — Othematoma is the only tumor which might be con- 
founded with cavernous angioma. The former is of rapid growth, 
smooth in outline, and opaque to transmitted light; whereas angioma 
usually develops more slowly, is irregular in outline, and is transparent to 
transmitted light. 

Treatment. — The treatment should be addressed to the reduction of 
the blood contents of the tumor, which interfere with its circulation. 
This may be accomplished in various ways. Electrolysis is, perhaps, the 
best method in growths of small or medium size. The needles con- 
nected with the positive pole of the battery should be thrust through the 
growth, while the negative (sponge electrode) pole is placed on some 
remote portion of the body. The positive pole liberates oxygen and 
acids, which coagulate the blood and soft tissues, thus contracting and 
obstructing the cavernous sinuses of the tumor. Should the negative 
pole be applied as recommended by Hovell, the results would be less 
certain, as the negative pole liberates hydrogen gas, which tends to 
liquefy the solid tissues. The negative pole is better adapted to use in 
fibrous tumors, on account of its liquefying properties. 

Multiple puncture of the surface with needle points and brushing the 
surface with nitric acid has been recommended in small growths. Both 
measures produce scar tissue, and thus cause contraction. 

Politzer recommends the passage of several silk sutures through the 
tumor. He first renders them aseptic and then saturates them in a solu- 
tion of the perchloride of iron. The iron coagulates the blood and the 
threads act as nuclei for the clot formations. 

The galvanocautery and the Paquelin cautery have been used in larger 
growths. Such treatment is necessarily limited to exceptional cases. 

Injections of styptic remedies, as carbolglycerin, iodine, and the 
perchloride of iron are not safe procedures, as they may cause extensive 
sloughing and subsequent disfigurement from cicatricial contraction. 
Suppuration and perichondritis may also follow the injections, the 
auricle becoming shrivelled and reduced in size. 

Fibroma. — Fibrovia of the external ear consists of s})indle ceils and 
connective tissue. It is usually the result of local irritation, as the wear- 
ing of ear-rings, and is often found in negresses, who are peculiarly 
])rone to fibromata, not alone here, but in other parts of the body also. 
They vary in size up to a large walnut, arc rounded in form, and may be 



618 



THE EAR 



pedunculated or sessile. They are usually located in the lobule, as this 
is the portion in which ear-rings are worn. They may appear elsewhere 
on the auricle or even at the entrance to the auditory canal (Fig. 349). 

Treatment. — If small, a V-shaped incision, including the growth, may 
be made, and the cut surfaces brought together by skin stitches, thus 
causing very little disfigurement. If the growth is pedunculated, it is 
easily removed with scissors, and the base cauterized and dressed anti- 
septically. I-,arge growths may be removed by excision, the parts being 
brought together as well as possible so as to avoid disfigurement. If 
necessary, a subsequent plastic operation may be performed to over- 
come the deformity. 

Cysts. — Like cyst formations in other parts of the body, they are the 
result of the plastic union of parts which are normally open or separated, 
i. e., the sebaceous glands of the auricle may become infected, their 




Fibrous tumor (keloid) of right auricle. (After Briihl-Politzer.) 



orifices closed, and the secretions retained in the dilated and inflamed 
glandular sacs. They are variable in size, are soft, and may remain 
stationary in their development for several years. 

Treatment. — The treatment of cysts of the auricle consists in a free 
incision into the tumor, the evacuation of its contents, curettement, and 
the application of the tincture of iodine to the surface of the cavity. A 
suitable surgical dressing should then be applied, and repeated daily 
while repair is taking place. 

Epithelioma. — The growth begins as a hard nodule situated in the 
skin or the subcutaneous connective tissue; it grows slowly for a time, but 
later develops quite rapidly. It is in this stage that ulceration is likely 
to occur. The growth may be an extension from contiguous structures, 
or it may be primary in the auricle or the meatus. Of the sixty cases 
reported, nearly all occurred in patients more than forty years of age. 
Dr. J. S. Brown reports a case in a man seventy-eight years old. Epithe- 
lioma may begin as warty or fissured surfaces, which finally ulcerate and 



NEOPLASMS OF THE EXTERNAL EAR 



619 



continue to spread by the formation of new tissue at the edge of the ulcer. 
This tissue rapidly undergoes disintegration, and the ulcerous process may 
spread until the entire auricle and meatus or even the neighboring 
structures are destroyed (Fig. 352). 



Fig. 351 




Fig. 350. — Sarcoma of auricle. 

Fig. 351. — Lupus vulgaris of auricle. 

Fig. 352. — Carcinoma of auricle and temporal bone. Lett ear of a man fifty-six years of age who 
had suffered from aural discharge. The carcinoma extended into the body to the temporal bone. 

Fig. 353. — Acquired stricture of external auditory meatus. Left ear of a man who had been 
run over by a wagon in early childhood. Immediately behind the opening of the auditory 
meatus there is a connective-tissue septum stretched across the canal like a diaphragm, with a 
round opening that admits a sound the size of a pinhead. He can hear whispered conversation 
at a distance of three meters. (After Briihl-Politzer.) 

The nodular enlargements on the auricle may be present several 
months before enlargement of the glands in the neck appears. Pain 
may not be a symj)tom until ulceration takes place; hence, in the early 
stage, epithelioma may be mistaken for fibroma. As the ulceration 
and the deeper extension of the growth progress, the pain increases, 
often becoming excruciating in character. The facial nerve may be- 
come involved, and facial ])aralysis develop. The auditory nerve may 
be affected, or luMiiorrlniges may occur, and glandular enlargements 



620 THE EAR 

develop, finally resulting fatally. Death may be due to septicemia, 
exhaustion, meningitis, thrombosis of the lateral sinus, or cerebral 
abscess. 

Treatment. — The treatment of epithelioma here, as elsewhere in the 
body, consists in the complete removal of the growth by excision. To 
accomplish this it may be necessary to remove the auricle in part; or 
entirely. The disfigurement resulting may be corrected by a subse- 
quent plastic operation or the adjustment of an artificial auricle. While 
the wound is healing a ^•ulcaniz;ed or a silver tube should be worn in 
the meatus to prevent cicatricial contraction. 

Sarcoma. — Sarcoma of the auricle is rare. When present, it may 
be of the round-cell variety, which develops rapidly and leads to an 
early fatal issue, or it may be of the fibrosarcomatous type, which grows 
slowly. This type may exist for many years without giving rise to 
marked symptoms. The round-cell variety is painful, as its rapid 
growth stretches the sensory nerves, and it is also often attended by 
inflammation in the parotid and the mastoid regions. 

The appearance of the tumor varies according to the variety and the 
rapidity of development. If it is of the fibro-sarcoma type, it is smooth 
and covered with normal skin. If it is of the round-cell variety, its 
growth is rapid. The skin becomes eroded and the seat of fungous 
granulations (Fig. 350). The eroded surface secretes an unsightly 
suppurating material composed of debris, pus, epithelium, leukocytes, 
and blood corpuscles. The ulcerating surface often bleeds profusely. 

The external meatus may be the seat of round-cell sarcoma and, in 
extremely rare instances, of osteosarcoma. 

Diagnosis. — A portion of the growth should be subjected to micro- 
scopic examination. The round-cell sarcoma is pale on cross-section 
and exudes a milky juice; it is composed almost entirely of round cells 
and thin-walled bloodvessels. The fibrosarcoma has a considerable 
quantity of intercellular cement substance, and the macroscopic appear- 
ance of the tumor is coarse-grained and firm. 

Prognosis. — It is obvious that this depends upon the type of the growth, 
the round-cell variety being comparatively more speedy and de- 
structive. In this type death may result from intracranial extension, 
hemorrhage, or exhaustion. 

Treatment. — Early and complete removal of the growth is the best 
treatment. This may be done with the knife or the galvanocautery. 
If the growth cannot be completely removed, the parts continue to dis- 
charge offensive material. 

The Rontgen-rays have been used with some apparent success in 
superficial sarcomata, but we are not ready to recommend this method 
of treatment until further trial has demonstrated its real value. It is 
unsafe to try it in the round-cell variety, as the early surgical removal 
offers the only hope in this type of sarcoma. While using the Rontgen- 
ray treatment extensions may occur, thereby rendering operative treat- 
ment hopeless. The rays are of special value, however, after opera- 
tion, recurrences being less frequent or delayed by their use. 



CHAPTER XXXVIL 

DISEASES OF THE AURICLE AND EXTERNAL MEATUS. 
PERICHONDRITIS OF THE AURICLE. 

This is a rare affection and resembles othematoma. The upper 
portion of the auricle is usually involved, as the cartilage is chiefly 
found there. The lobule escapes, as it is free from cartilage. 

Symptoms. — If the inflammation occurs as a complication of 
furunculosis of the meatus, the pain characteristic of that condition is 
present; whereas, if it begins in the auricle, the first symptom may be 
circumscribed redness and swelling, which gradually spreads and be- 
comes more pronounced, until it finally involves the whole of the car- 
tilaginous portion, including the concha, or it may include the meatus. 
If the meatus is wholly occluded by the swelling, the hearing is impaired. 
Fluctuation soon appears, and is due to the inflammatory exudate 
of viscid serum beneath the perichondrium. The natural contour 
of the auricle is modified by the swollen tissue and its surface is red- 
dened. The perichondrium of the entire auricle may become detached 
and thus interfere with the nutrition of the cartilage. This is a serious 
complication, especially if the secretion becomes purulent. Under 
such circumstances the cartilaginous auricle is apt to shrink or slough, 
and leave pronounced deformity. 

The greatest care should be exercised to prevent additional infec- 
tion when there is an abrasion of the skin and when an incision is made 
to evacuate the fluid beneath the perichondrium. 
Should active infection be present, many weeks Fig. 354 

or months may be required to check the progress 
of the disease, and even then the auricle will be 
greatly deformed. Perichondritis occasionally fol- 
lows the mastoid operation, especially when the 
plastic meatal flap includes the concha of the auricle. 

Tlie result of the perichondritis may be so slight 
as to attract no attention, or it may be so marked 
as to completely disguise the anatomical characteris- 
tics of the auricle. 

Treatment. — The treatment sliould be antiphlo- 
gistic in nature, heat being the most serviceable lAini's ,;,i\. 
in the early stage. The Leiter coil (Fig. 354) 
should be applied over the auricle and hot water passed through it. 
A hot-water bag may also be used. A brisk saline cathartic should 
be administered and leeches used around the auricle in conjunction 




622 THE EAR 

with the heat. If fluctuation is present, an incision should be made 
to evacuate the fluid. The auricle should be cleansed before making 
the incision, to prevent the possibility of additional infection. The 
cavity should be carefully but thoroughly scraped with a dull curette, 
and then cleansed with an antiseptic solution. If the infection is 
severe and granulations are present, the cavity should be swabbed with 
the tincture of iodine or the compound tincture of benzoin. Free 
drainage should be maintained by the insertion of a gauze wick, over 
which the usual dressing of gauze and cotton should be placed and 
held in position with a bandage. The dressings should be changed 
every twelve hours. 

Subsequent operative measures may be undertaken to correct the 
deformity if it is sufficiently pronounced to produce disfigurement. 



HERPES OF THE AURICLE. 

The etiology is not always clear, although it seems to be caused by 
middle-ear disease. It is thought by some to be caused by malaria, 
and by others to be a neurosis. It is most common in adults. 

Symptoms. — The vesicular eruption is sometimes preceded by a 
stinging or burning pain, especially if the meatus is involved. The 
eruption is generally on the outer or concave surface of the auricle, 
which is supplied by the auriculotemporal branch of the fifth nerve. 
This is of interest, as the distribution of the eruption usually follows 
the terminal ending of this nerve. It is more rarely on the posterior 
or convex surface of the auricle, as the auriculotemporal branch of the 
fifth nerve does not extend to this region. 

The course and appearance of the eruption is about as follows : 

At first there is a reddened area, which becomes papular, then visic- 
ular. The vesicles may become confluent and form bullae. The con- 
tents of the vesicles is first clear serum, which later becomes cloudy 
and purulent. The duration of the vesicular stage is limited to a few 
days, after which the vesicles dry up, leaving crusts and an occasional 
superficial ulcer. 

If the meatus becomes involved, more or less deafness and tinnitus 
is present. 

Treatment. — ^Tonics, purgatives, and outdoor exercise are indi- 
cated to improve the general health of the patient. Cool or cold morn- 
ing baths, or at least sponging of the neck and chest, are indicated to 
improve the tone of the vasomotor nervous system. 

The blisters should be protected by starch or boric acid powder and 
cotton -wool dressings. The fluid contents of the vesicles should be 
emptied, care being taken to avoid removing the elevated dermis, and 
exposing the underlying parts to the air. This accident is attended by 
considerable pain. Boric acid powder may be applied in suppurative 
cases. If the meatus is involved, boric acid should be blown into it. 



DERMATITIS OF THE AURICLE 623 



HERPES ZOSTER OF THE AURICLE. 

This is a vesicular eruption appearing on a reddened surface, although 
the area of redness does not extend much beyond the base of the blis- 
ters. The vesicles are arranged in groups and are quite painful. 

They most often appear upon the posterior surface of the auricle and 
the lobule, and more rarely upon the anterior or superior surface of the 
meatus. They still more rarely develop upon the anterior surface of the 
auricle. 

It is a nervous affection of either the trigeminus or the great auricular 
nerve. In some cases it seems to be of ganglionic origin. 

The location of the eruption is determined by the distribution of the 
nerve affected. 

In rare instances the drumhead is involved, although the hearing 
may be but slightly affected thereby. Within a few days after the for- 
mation of the vesicles they burst, emptying their contents, after which 
crusts form at the site of the eruption. 

A few days later new epidermis forms, and unless there is a recurrence 
of the disease complete recovery takes place. 

Treatment. — Although herpes has been recognized as a distinct 
disease for a long time, the treatment of it has not developed beyond an 
attempt to relieve the pain and to prevent excoriations after the bursting 
of the vesicles. The internal administration of arsenic is often recom- 
mended with the idea of correcting the nervous disorder which is the 
chief cause of the trouble. It is doubtful, however, if it has any specific 
effect as a remedy. Anodyne remedies, such as the 5 per cent, 
ointment of the hydrochlorate of cocaine, may be applied locally with a 
fair degree of confidence that it will afford relief. Calomel dusted over 
the eruptions, especially after they have discharged their contents, in- 
duces healthy and speedy epidermization of the denuded surfaces. 



DERMATITIS OF THE AURICLE. 

Dermatitis may be due to traumatism, exposure to heat or cold, and 
to a parasitic infection (Politzer). The treatment should consist of the 
application of solutions of lead. 

It occasionally happens that when there is an abrasion of the skin of 
the auricle or a loss of the integrity of the epidermis due to eczema, 
etc., erysipelatous infection may occur and lead to a much more severe 
type of inflaniraation. 

Treatment. — The treatment should be antiphlogistic in character 
and weak sohifions of ichthyol (1 to 5 per cent.) should be applied 
locally. 

Should the deeper tissues become involved and pus accumulate 
therein, free incisions should be made and the parts treated according 
to aseptic surgical principles. 



624 THE EAR 

Dermatitis from Exposure to Cold. — Synonyms. — Frostbite; chil- 
blain; dermatitis congelationis aiiriculse. 

Etiology. — Exposure to extreme cold or prolonged exposure to moder- 
ate temperature, as in the autumn of northern latitudes, also the ex- 
treme thinness of the skin and slight amoimt of subcutaneous tissue 
separating it from the cartilage of the auricle predisposes to dermatitis. 

The disease is characterized by the formation of nodules and excoria- 
tions, especially on the elevated portions of the auricle. 

In the extreme nortli, the dermatitis is usually acute in character and 
is attended by simultaneous freezing of the nose. More or less necrosis 
and gangrene, and partial loss of the auricle follows. 

Ordinary frostbite is characterized by moderate swelling, redness, 
and circumscribed dermatitis. 

The nodules heal slowly or not at all, and become covered by bloody 
crusts. Even after the crusts disappear the skin continues to exfoliate 
epidermis for a long time. The affection is most common in young 
chlorotic girls of northern climates, and always appears at the beginning 
of cold weather. It is more than probable that insufficient and improper 
food predisposes to its occurrence. These conditions together with the 
unstable vasomotor system at the time of puberty may be considered 
the chief etiological factors. 

Symptoms. — In addition to those apparent to the eye, as described 
al)o^'e, may be mentioned lancinating pains, sense of heat, itching, 
etc. These symptoms cause the patient to scratch or rub the parts, 
thereby increasing the difficulty. 

Treatment. — In those cases due to extreme cold, snow or ice-bags 
should be applied. In the subacute varieties, Goulard's extract is ser- 
viceable. The auricle may be painted with iodine collodion, or cam- 
phor ointments may be used. For the relief of the intolerable itching 
the following mixture is of value: 

IJ— Collodion 5J 

OI. ricini Tf\xx 

01. terebinth 5j — M 

Sig. — Apply locally to relieve itcliing. 

The frequent application of camphor ointment also relieves the itching. 



FURUNCULOSIS OF THE EXTERNAL MEATUS. 

Synonyms. — J'ollicular inflammation of the external auditory canal; 
otitis externa; follicularis s. circumscripta. 

Etiology. — Furunculosis of the external auditory canal is a cir- 
cumscribed inflammation involving either the hair follicles or the sudo- 
riferous glands. As these organs are limited to the cartilaginous or ex- 
ternal portion of the canal, the furuncles are not found in the deeper or 
osseous portion. The boils may be without knowm cause, or they may 
be a part of a general furunculosis. They may occur in the course of 



FURUNCULOSIS OF THE EXTERNAL MEATUS 625 

suppurative otitis media and chronic eczema. Traumatism from 
attempts at cleaning the ears often causes them. It most often appears 
in the spring and autumn, and is chiefly a disease of adult life. General 
debilitating diseases or their sequelae predispose to it. 

Symptoms. — The hearing is but slightly affected in most cases, as 
the lumen of the canal is not completely obstructed. The pain is more 
or less intense according to the depth of the inflammatory process. The 
furuncle does not always present the appearance of a boil, as the skin is 
tense and closely adherent to the cartilaginous meatus, thus preventing 
the usual elevated appearance. In other words, the swelling is more 
diffused and but slightly elevated. 

The auricle is extremely sensitive to the touch, and the movements of 
the inferior maxilla in mastication cause pain. The tension of the skin 
becomes so great that the patient is often unable to sleep. The swelling 
in the external meatus is more or less diffused on account of the close 
adhesion of the skin to the cartilaginous meatus, and with the inexperi- 
enced may be mistaken for the redness and swelling in the postsuperior 
portion of the meatus in mastoid inflammation. It is easily differen- 
tiated from it, however, by remembering that the swelling due to mas- 
toid disease is limited to the postsuperior wall of the osseous or deeper 
portion of the meatus, while that due to furunculosis is in the posterior 
and inferior wall of the outer or cartilaginous portion. The pain is 
often greater in furunculosis. 

The temperature is irregularly elevated during the first few days. 
Deafness and tinnitus are present if the meatus is occluded, though 
they may be present without occlusion. When this is the case the in- 
flammation has probably extended to the drumhead and the tympanum. 

The more superficial the furuncle the greater the redness and the 
more circumscribed its area. Pain may or may not be present. If the 
deep tissues are involved the redness and swelling are more diffused, 
while the pain is greater. In some cases the surrounding tissues 
become more or less swollen, as, for instance, when the anterior por- 
tion of the meatus is involved, the skin in front of the tragus is swollen 
and purple in color; whereas if the posterior portion is involved, the 
mastoid skin may be swollen and simulate mastoiditis. Glandular en- 
largement in the lateral region of the neck is not commonly present. 

Course. — Furunculosis of the meatus is apt to go on to suppuration, 
which usually takes place in from six to eight days. The deeper the 
inflammation the more delayed the voluntary escape of pus. The 
pain and swelling subside immediately after the pus is liberated, 
especially if it is done by incision. Incisions should be made early, as 
the progress of the disease is often thereby checked. The meatus 
should then be irrigated with warm boric acid solution, thoroughly dried 
and dusted with bismuth, and a gauze wick inserted for drainage. The 
dressing should be changed daily until the swelling and discharge have 
materially subsided. If the boil is allowed to rupture spontaneously, 
granulations may spring from its crater, and be mistaken for middle- 
ear polyp. Recurrences are to be expected in many cases. 
40 



626 THE EAR 

Treatment. — Abortive treatment may be used before the forma- 
tion of j)U.s has taken place. The best remedy is a 5 per cent, sohition 
of carboHc acid in glycerin. This should be instilled into the meatus, 
or applied with a cotton-wound applicator if the canal is open. Its 
early use is often followed by a complete disappearance of the process. 
The Leiter ice coil gives relief to the pain. Mixtures containing opium, 
morphine, cocaine, etc., are recommended, but the carbolic-glycerin 
mixture is not only curative, but analgesic as well. Poultices have 
been recommended, but their use is irrational and obsolete. Antiseptic 
solutions are valuable adjuncts in the treatment of furunculosis, and 
the carbolic-glycerin solution answers this purpose admirably, in addi- 
tion to its anodyne and curative properties. Should it fail to give the 
desired relief, the meatus is at least prepared for operative measures. 

In a large majority of cases the process has gone on to the suppurative 
stage before the physician is called in. When pus is present the furuncu- 
lous area should be freely incised with a narrow bistoury. Pus may not 
appear at once, but this should not deter the physician from incising 
each swollen and reddened area. If voluntary rupture has occurred 
and the flow of pus is obstructed by granulations the area should be 
opened more freely. 

After-treatment. — Immediately after incision the cavities exposed 
should be cleansed with a 5 per cent, solution of carbolic acid to check 
the growth of the pus cocci. Frequent instillations of hydrozone 
should be used to keep the wound and the meatus free from pus. 

The ceruminous secretion is often absent after an attack of furuncu- 
losis, or, if present, is of a dry, crumbling quality. Intolerable itching 
usually complicates furunculosis. 

Various remedies for the relief of the itching have been recommended. 
The white precipitate ointment, boric acid 5 per cent, in lanolin, and 
the glycerin-carbolic acid solution are valuable for this purpose. 

The entrance of water into the meatus often leads to a relapse, hence 
care should be exercised to prevent it. 



DIFFUSED INFLAMMATION OF THE EXTERNAL MEATUS 

Synonyms. — Otitis externa diffusa. 

Etiology. — The causes are (a) infections from without and from 
within the middle ear; (b) traumatism; (c) excoriation of the cutis of 
the meatus; and (f/) the injection of irritating fluids into the meatus. 

Sjnnptoms. — Unlike the furunculous type, the symptoms are chiefly 
limited to the osseous meatus and the drumhead. The cutis is swollen 
and congested, and after a few days throws off a serogelatinous secre- 
tion, which is often so tenacious that it can be removed en masse 
(Politzer). It is charged with pathogenic organisms, thus showing its 
bacteriological origin. 

Great 'pain in the region of the ear is usually present, movements of 
the inferior maxilla aggravating it. Tinnitus and dizziness are occa- 



HEMORRHAGIC INFLAMMATION OF THE MEATUS 627 

sionally present. The hearing may be impaired, especially if the drum- 
head is much swollen, or if there is a large accumulation of thick secre- 
tion. 

The duration of the disease is three or more days. If it runs an un- 
interrupted course, an acute case may terminate on the third day. The 
hearing is usually normal after the inflammation ceases. In rare cases 
an excoriated or ulcerous surface is left, and becomes the seat of a granu- 
lation tumor, which, when removed, checks further pus secretion. 

Periostitis and hyperostosis may be left as sequelae in rare cases. 

Prognosis. — In the simple forms complete recovery usually occurs, 
while in those cases complicated by excoriations, injuries, etc., con- 
striction of the meatus from periostitis, hyperostosis, and dermoid thick- 
ening are liable to affect the function of the ear. 

Treatment. — It should be borne in mind that the disease is usually 
of bacteriological origin, and remedies applied accordingly. The car- 
bolic-glycerin mixture (5 per cent.) is, perhaps, one of the most reliable 
remedies. It should be instilled into the meatus two or three times 
daily and cotton-wool introduced into the cartilaginous canal. The 
Leiter coil, and leeches to the tragus and the mastoid region are of great 
value when there is swelling and pain. Antiseptic solutions of all kinds 
have been recommended, but it is doubtful if any of them are of espe- 
cial value. It may be said of aqueous solutions in general that their 
utility is questionable. Remove the secretions from the meatus with 
hydrozone and a cotton -wound applicator and then apply the carbol- 
glycerin mixture. 

If ulcers form and show no tendency to heal, they should be cauterized 
with a 90 per cent, solution of the nitrate of silver. 



HEMORRHAGIC INFLAMMATION OF THE MEATUS. 

Synonym. — Otitis externa hemorrhagica. 

Tills is a form of hemorrhage beneath the superficial layer of the skin 
of the osseous meatus, and in most cases is probably a complication of 
influenza otitis media. The hemorrhagic areas appear as bluish swell- 
ings on the inferior or the posterior wall of the meatus. To the probe 
they are soft and often rupture upon very slight pressure. The vesicles 
may remain for several days, and when they disappear others may come 
to take their place. In from one to two weeks they disappear altogether, 
(•f)inplete recovery taking place. The hearing, if afl'ected, returns to 
nonnal. 

Treatment. — 'i'lic licmorrliagic vesicles should be opened with a 
pi'ohc and gjiii/c draiiKige a|)])li('d to the meatus. The dressing should 
be removed (hiilv. l'oli(/cr i-ccoiiuiu^nds dusting the meatus with boric 
acid powder in ad(n(i()n (o (he gau/c (h-ainag(\ 



628 THE EAR 



CROUPOUS INFLAMMATION OF THE MEATUS. 

Synonjma. — Otitis externa crouposa. 

I'liis is a very rare condition, and usually occurs in connection with 
influenza otitis media or furiniculosis of the meatus. The false mem- 
brane is limited to the osseous portion of the meatus and to the outer 
surface of the drumhead, being in this particular similar to the diffuse 
inflammation of the meatus. It sometimes appears with a similar 
process on the tonsils (Gottstein). The membrane forms in from one 
to two days and is firmly attached; it may, however, be removed by 
forcible syringing. It may form a cast of the osseous meatus and the 
drumhead. The microscope shows it to be composed of a fibrous 
network infiltrated with round cells, nuclei, epithelium, staphylococci 
pyocyaneus, and streptococcus pyogenes (Politzer). 

The formation of the membrane is attended by some pain, which 
disappears when it is cast off. Recurrences are common. 

Prognosis. — The prognosis is favorable. In rare cases the cartilage 
of the meatus becomes necrotic or gangrenous. 

Treatment. — The treatment consists in removing the false mem- 
brane with forceps or by antiseptic solutions applied with a syringe. 
Dry the meatus and dust with an antiseptic powder. 



EXOSTOSIS AND HYPEROSTOSIS OF THE MEATUS. 

These two terms are often used s}Tionymously, although, according 
to strict pathological interpretation, they should be used to describe differ- 
ent lesions of the bony tissue. 

Exostosis refers to a bony tumor growing from the wall of the meatus, 
and it may be either sessile or pedunculated. Hyperostosis is a diffuse 
thickening of the bony tissue, or a true hyperplasia. 

Etiology. — The cause of these pathological changes is often un- 
knoA\Ti, but in many instances they are due to conditions which may be 
easily recognized. Among them may be mentioned: 

(a) Traumatic fracture of the walls of the meatus, whereby a cir- 
cumscribed periostitis is excited, finally resulting in the formation of a 
bony mass or tumor. • 

(fe) They may be due to developmental causes, particularly in those 
cases wherein the middle and the inner section of the osseous meatus on 
each side is the seat of the growth. When it is due to faulty develop- 
ment the growths are usually small. They may be either sessile or 
pedunculated. 

(c) Chronic suppuration of the middle ear may excite a secondary 
inflammation of the membranous canal, and cause a fibrous or connec- 
tive-tissue thickening, which, after a long period of time, may be meta- 
morphosed into osseous tissue. 

{d) There are some cases in which heredity seems to be a factor in the 



EXOSTOSIS AND HYPEROSTOSIS OF THE MEATUS 629 

production of the growths, as the same condition may be traced through 
a few generations. 

(e) Syphihs is undoubtedly a cause of the growths, although not in 
a very large number of cases. 

(/) Gout has been thought to be another cause, but it is doubtful if 
this condition directly leads to their formation. 

It is more probable that the gouty diathesis causes an inflammatory 
process of the skin and the periosteum, which finally undergoes a retro- 
grade change and becomes the seat of lime deposit. 

Sjrmptoms. — The symptoms are chiefly those recognizable by the 
aid of the eye and the probe, although in some cases in which the lumen 
of the ear is completely occluded the function of hearing may be affected. 
If the growth is an exostosis, it appears as a rounded, elevated mass, 
with a tense, whitish skin covering. The lumen of the meatus is re- 
duced to a crescentic or slit-like opening. The swelling or growth is 
composed of very dense tissue. If it is sessile, it will be difiicult to 
differentiate between it and a hyperostosis, but if it is pedunculated the 
differential diagnosis may be more easily made, as this type of growth 
is more often an exostosis. A favorite seat for the growths is at the 
junction of the osseous and the cartilaginous portion of the meatus. 
They may, however, form in any portion of the canal. Deafness may 
be present, although it is not marked, unless there is concurrent disease 
of the middle ear or the labyrinth, except in those cases in which the 
growth completely obstructs the lumen of the canal. Secondary inflam- 
mation of the cutaneous meatus may be caused by the pressure of the 
growth against the opposing walls. In such cases there will be more or 
less secretion from the dermatitis thus excited. Cases have been re- 
ported in which the pressure of the growth was so great that necrosis of 
the surrounding bone tissue resulted, thereby complicating the case. 

Treatment. — The treatment is necessarily limited chiefly to surgi- 
cal procedures, except for the relief of those symptoms which are due to 
secondary inflammatory processes. If the growth is large enough to in 
any way interfere with the function of audition, it should be removed. 
In some cases this can be done through the external auditory meatus 
without lifting the auricle forward, as is done in the mastoid operation. 
The skin and periosteum over the growth should be excised and 
elevated, and the bony mass removed or reduced with a small chisel 
or gouge or with a dental burr or trephine. If the growth is sessile 
or diffused, and involves the entire length of one wall of the meatus, 
it would, perhaps, be futile to attempt to remove it through the external 
auditory meatus. A better and much simpler procedure would be to 
first lift the auricle forward, as in the mastoid operation, thus exposing 
the entire canal to view and afl'ording easy access with instruments. 
When this is done the skin of the osseous portion of the meatus should 
be carefully elevated with a small periosteum elevator, so that the heal- 
ing process may be more certain and rapid after the operation. The 
exposed tumor should then be removed with a very sharp gouge, or, 
perhaps better still, by the use of a dental burr. This method of pro- 



G30 THE EAR 

cedure is also productive of better results in many of the pedunculated 
growths, as the base can thus be completely removed. 

The indications for operative interference should be based upon the 
amount of deafness present and upon the concurrent middle-ear disease, 
if present. For example, if there is chronic suppurative ear dis- 
ease, with impairment of hearing, it is quite essential to the proper 
treatment of the case that the external auditory meatus be completely 
freed from the obstructive lesion, so as to afford better drainage and 
opportunities for treatment. 

Another indication is the presence of dermatitis with secretions, while 
a still more urgent indication is secondary pressure necrosis of the con- 
tiguous tissue. 

It seems irrational, in view of the present status of surgery, to resort to 
the use of laminaria tents for the dilatation of the canal, as the process 
must necessarily be a long and painful one. This method was formerly 
in vogue and is still recommended in some of the modem text-books on 
otology. 

STRICTURE OF THE EXTERNAL MEATUS. 

Etiology. — Obstructive lesions of the external auditory canal are 
due to the inflammatory swelling of the skin lining its walls, as described 
under dermatitis, furunculosis, perichondritis, eczema, etc. It may 
also be due to new-growtlis, exostosis, and fibrous thickening of the 
deeper dermic tissue. It is to the last-named condition that permanent 
obstruction of the lumen of the canal is usually due. 

Cicatricial rings or bands are produced by prolonged inflammation 
of the meatus in the course of chronic otorrhea. In rare instances they 
are due to syphilis, diphtheria, etc., or to the use of the cautery and acids 
in the meatus. Partial closure of the canal sometimes follows the mas- 
toid operation, especially if the plastic meatal skin flap is not properly 
sutured and the wound is tightly packed with gauze. (See Mastoid 
Operation.) In the aged the cartilage supporting the skin of the meatus 
undergoes atrophic changes, which allows the walls to collapse and ob- 
struct the meatus. 

In some cases the obstructing lesion is ring-like, while in others it may 
be limited to one wall of the meatus. If it is due to an exostosis, there 
is a tumefaction on one side of the canal. The tumor is hard to the 
probe touch, and may either partially or wholly obstruct the meatus. 
Exostosis sometimes follows the exfoliation of necrosed bone, wdiile in 
other cases it develops from the periosteum or from the bone beneath 
as a hyperostosis. 

Treatment. — As the origin of the obstruction is various, so should 
the treatment be varied. If inflammatory, suitable treatment should be 
instituted. If it is cicatricial in character, laminaria tents and the 
subsequent introduction of hard-rubber tubes may be used. In this 
way the structure is dilated, and maintained in this condition by the 
rul)ber tubes. Electrolysis may also be used with advantage, from 



DIPHTHERITIC INFLAMMATION OF THE EXTERNAL EAR 631 

five to six sittings being required to reduce the fibrous constrict on. 
The needles connected with the negative pole of the galvanic battery 
should be inserted into the fibrous ring, while a large sponge electrode 
connected with the positive pole is placed in contact with the body. 
The amount of current necessary to soften the tissue varies from 25 to 
50 ma., and each seance should last from five to twenty minutes, accord- 
ing to the amount and the density of the fibrous tissue. 

Another method of dealing with fibrous strictures is to split the canal 
longitudinally in several parallel lines and introduce sponge tents. 
After thorough dilatation the hard-rubber tubes should be used to 
maintain the patency of the meatus. 

Jansen resorts to a surgical procedure which is probably the most 
successful mode of treatment, whether the stenosis is cicatricial or 
osseous in character. He detaches the auricle as in the mastoid oper- 
ation, and then dissects away the fibrous ring, osteoma, or hyperostosis. 
To cover the bony wound, he makes a pedunculated flap from the skin 
over the mastoid process and inserts it through the line of incision made 
in detaching the auricle. 

Should the stricture be of long standing and accompanied by sup- 
puration of the middle ear, a radical mastoid operation should be done, 
during which the canal may be enlarged. 



DIPHTHERITIC INFLAMMATION OF THE EXTERNAL EAR. 

Etiology. — It is obvious that diphtheritic inflammation of the ex- 
ternal ear can only occur when there is a denuded surface or a pre- 
existing inflammation. Croupous inflammation or excoriations from 
suppurative otitis media predispose the skin of the meatus and the au- 
ricle to receive the infection of diphtheria. It may appear primarily 
on the external ear during an epidemic of diphtheria, although it is 
usually associated with diphtheria of the fauces. If it is primary on the 
external ear, it may extend secondarily to the fauces. 

Symptoms. — The appearance and the characteristics of the mem- 
brane are the same as those found in the faucial type. It is of a dirty 
grayish color, closely adherent to the surface beneath, which, when the 
membrane is forcibly removed, bleeds. There is more or less pyrexia, 
pain, tinnitus, and deafness. The cervical and the postauricular glands 
are swollen and slightly painful. 

The course of the disease is not unlike that of croupous inflammation 
of the same parts. The membrane may reform a number of times, 
thus indefinitely prolonging the disease. If deep ulceration occurs, and 
the disease is prolonged, the canal is more or less obstructed and may 
ultimately lead to serious stenosis; on the contrary, if only the super- 
ficial parts are involved, the obstruction is temporary. 

Diagnosis. — '^riie diagnosis here, as in faucial diphtheria, is clinical 
and microscopic. The membrane is closely adherent, and the surface 
from which it is removed bleeds freely. I'he microscope reveals the 
presence of Klebs-Loeflfler bacilli. 



632 THE EAR 

Prognosis, — The absorptive power of tlie skin of the meatus is not 
great when compared with that of a mucous membrane. Diphtheria, 
when hmited to the external ear, is not a grave disease. If, however, it 
is compHcated by middle-ear or faucial diphtheria it is correspondingly 
more serious. If the middle ear is involved, there may be great destruc- 
tion of the drumhead with necrosis of the ossicles, the tympanic walls, 
and the labyrinth, thereby causing serious impairment of the function of 
hearing. 

Treatment. — The treatment is somewhat simpler than that of 
faucial diphtheria on account of the greater vulnerability of the tissue 
affected, and its lesser absorptive power; also by the ease with which 
local remedies may be kept in constant contact with the diseased sur- 
face. Burckhardt-Merian and Gottstein recommend filling the external 
meatus with lime-water at frequent intervals, leaving it there for fifteen 
or twenty minutes. It is supposed to loosen the membrane and favor 
its discharge. The author has used lime-water extensively for this pur- 
pose in this and faucial diphtheria, and regards it very favorably. After 
using it the parts should be covered with a powder composed of equal 
parts of the subnitrate of bismuth and salicylic acid. Nearly all the 
antiseptic powders and solutions have been used for this purpose, but 
none of them has equalled, in the author's experience, the lime-water and 
bismuth-salicylic acid treatment. 

The usual constitutional remedies and the administration of anti- 
toxin should be used as in the faucial disease. 



MYCOSIS OF THE EXTERNAL MEATUS. 

Synonyms. — Parasitic inflammation of the external auditory canal; 
otomycosis. 

Etiology. — The source of the mycotic infection is often unknown. 
Living in damp surroundings or in the presence of yeast spores seems 
to favor it; hence it is rather common among bakers. The habit of 
instilling warm oil into the ears to relieve earache favors the growth 
of the spores, as the oil is a good soil for their development. The spores 
most commonly causing the disease are the Aspergillus niger, fiavus, and 
fumigatus. Several other varieties are occasionally found. 

It usually occurs in adults, rarely in children or in the old. As the 
sanitary and hygienic conditions surrounding the poor are bad, it is com- 
mon among them. The fungus growth may, in rare cases, extend to the 
middle-ear cavity or even to the mastoid cells. 

Symptoms. — The manifestations of the infection depend largely 
upon whether the spores have attacked only the epidermis or also the 
deeper living structures of the skin or the drumhead. If only the epi- 
dermis is affected, there may be no symptoms, even when the drumhead 
is covered with the false membrane; on the contrary, if the true skin is 
involved deafness and tinnitus are more or less pronounced as a result of 
the swelling and inflammation excited. This type of inflammation is 



ACUTE ECZEMA OF THE EXTERNAL EAR 633 

known as otitis externa parasitica, and is characterized by shooting 
pains, itching, tinnitus, and deafness. 

The appearance of the mycotic membrane is black or grayish in color, 
velvety in texture, and distributed chiefly over the osseous portion of the 
canal, although the drumhead and the cartilaginous portions of the 
canal may also be covered by it. It can be removed by the syringing. 
The underlying skin is red, slightly swollen, and largely denuded of 
epidermis. 

The course of this type of inflammation, if not properly treated, may 
extend over several weeks. Under treatment its duration may be much 
shortened. 

The pains and other subjective symptoms are usually greatly relieved 
immediately after the removal of the membrane. 

Treatment. — Almost the entire list of antiseptic mixtures and 
powders have been used for the relief of these cases, but the remedy par 
excellence is alcohol, which should be instilled into the meatus once or 
twice daily, two to four days usually being sufiicient to effect a cure. 
The alcohol should be used at intervals every two weeks for a few months 
to prevent recurrences. 

ACUTE ECZEMA OF THE EXTERNAL EAR. 

The superficial layers of the skin are involved, and, in the beginning, 
there is marked redness and swelling of the skin; nests or colonies of 
fluid-filled vesicles soon make their appearance. 

Etiology. — It is not always possible to ascribe a cause for the erup- 
tion, although it is usually due to one or more of the following factors: 
viz., neuroses, scrofula, rickets, pus discharge from the middle ear, irri- 
tating remedies, cold douches, and exposure to heat. Other causes exist 
in selected cases. It may be a primary affection or it may be secondary 
to a similar process on some other part of the body. 

Symptoms. — The onset of the disease is characterized by burning 
and itching, which is soon followed by pain. Deafness and tinnitus are 
present in those cases in which the meatus and the drumhead are in- 
volved, especially when epidermis and secretions obstruct the lumen of 
the canal. If the disease is limited to the auricle, the hearing is not 
affected. There is some elevation of the temperature, especially in 
children. The pain and the pyrexia give rise to restlessness and in- 
abiHty to sleep. 

The disease may terminate in one of three ways, namely: (a) In the 
mild form the vesicles dry up and the epidermis peels off on the second or 
third day, leaving the natural cuticle. (6) In a large number of cases 
the Ijlisters discliarge their contents and after a few days the surface 
becomes covered with yellow crusts. In time these disappear and 
recovery takes place, (c) The third and more aggravating mode of 
termination is the persistence of a clear or purulent secretion for several 
weeks, after which the parts become covered with epidermis. 

In some cases the eczema may persist in isolated areas for many weeks 



634 THE EAR 

and leave more or less scar tissue and contraction, or it persists and 
becomes typically chronic in character. 

The treatment will be considered under Chronic Eczema. 



CHRONIC ECZEMA OF THE EXTERNAL EAR. 

Sjrmptoms. — Owinn^ to the involvement of the deeper structures of 
the skin there is greater thickening and rigidity of the auricle. The 
crusts usually form in the hollows of the auricle and in the posterior 
groove, while beneath them is secreted a serous or purulent matter. The 
meatus may be obstructed by the thickening of its integument. The 
whole auricle, and in some cases the meatus, is the seat of a desqua- 
mative process. The process of desquamation and crust formation 
varies in different cases, although the desquamation is usually predom- 
inant. 

Exclusive of the appearance of the skin, the itching is the most 
pronounced symptom. The patient is overcome with an irresistible 
desire to rub or scratch the parts, and thus produce deeper lesions of the 
skin. 

Tinnitus and deafness may result from desquamative plugs in the 
meatus and from secondary hyperemia of the mucous membrane of 
the middle ear. It is barely possible that in rare cases hyperemia of the 
labyrinth may be induced. 

The course of chronic eczema is quite diiferent in individual cases, 
some getting well under treatment in a few weeks, while others obsti- 
nately refuse to recover under any form of treatment. Boils in the 
meatus may complicate the condition. 

Treatment. — The general treatment should be addressed to the 
correction of constitutional dyscrasias and neuropathic states which so 
often underlie the condition. Iron, arsenic, strychnine, iodine, and the 
bitter tonics should be given in suitable combination for this purpose. 
The administration of saline cathartics and an occasional dose of calomel 
will often aid in overcoming the eczema. 

Perhaps one of the best measures for its relief is negative in character, 
namely, the avoidance of the local application of water, which greatly 
aggravates the eczema. If it is desirable to use water for toilet pur- 
poses, the patient should be instructed to add boric acid or even a tea- 
spoonfid of common table salt to the quart of water. The irritating 
qualities of the water are thus reduced. 

The local treatment is somewhat different in the acute and the chronic 
forms, hence they will be considered separately. 

Local Treatment of Acute or Subacute Eczema. — The remarks concerning 
the avoidance of plain water are especially applicable to this type of 
eczema. If proper care is exercised, some cases will get well with no 
local or constitutional treatment whatever. Others will persist in spite 
of any mode of treatment, and gradually pass into the chronic form. A 
soothing ointment composed of one dram of the oxide of zinc to the ounce 



CHRONIC ECZEMA OF THE EXTERNAL EAR 635 

of lanolin or vaseline is very sedative, especially if the disease is due to an 
irritating discharge from the middle ear. The addition of one grain of 
the acetate of morphine will increase the sedative action of the ointment. 
Calomel dusted on the excoriated or fissured surfaces acts well in some 
cases. Lotions of liquor plumbi subacetatis and resorcin are indicated 
when there are large vesicated surfaces. As their application excites 
pain, the parts should previously be painted with a 5 per cent, solution 
of cocaine. Ichthyol in aqueous solution (2 to 50 per cent.) has proved 
a valuable remedy. The parts should be painted once or twice daily. 
Cotton pads may be applied over the painted surface to prolong the 
therapeutic effect of the remedy and protect the diseased area from 
the air. 

When the case is in the crust-forming stage proceed as follows : 

(a) Remove the crusts by first softening them for twenty-four to 
forty-eight hours by local applications of oil, vaseline, lanolin, balsam of 
Peru, or Burow's mixture, 10 per cent, strength. If the oily prepara- 
tions are used, cotton should be saturated with them and applied over 
the scabs, and protected by another pad of gauze lightly held in position 
by a bandage. If Burow's mixture is used, the pads of cotton saturated 
with it should be covered with oiled silk or rubber cloth to prevent evapo- 
ration. Change every two hours. 

(6) At the end of twenty-four hours the crusts may be removed with 
a probe or forceps. Great care should be exercised to avoid inflicting 
injury to the underlying surface, as to do so causes a larger crust to 
appear. 

(c) The parts are now ready for the medicated ointments referred to 
above. They should be changed every day. The parts should be care- 
fully cleansed each time by wiping them with cotton pads, water being 
carefully avoided. In obstinate crust formation the parts should be 
painted with a 1 to 3 per cent, solution of the nitrate of silver before 
reapplying the salve. 

{d) When epidermization is established the new skin should be pro- 
tected from mechanical or chemical (water) irritants by the use of 
simple ointments for several weeks. If this is not done recurrences 
are apt to take place and the hyperemia present in this stage exagger- 
ated. 

Local Treatment of Chronic Eczema. — It is rather difficult to outline a 
definite line of procedure in chronic squamous eczema, as so many reme- 
dies are recommended, none of which may be depended upon except in 
selected cases. 

Those remedies which soften the scaly epidermis and reduce the hyper- 
emia of the skin afford the best results. 

To soften the scaly epidermis, vaseline, lanolin, or olive oil should be 
rubbed in once or twice daily; or a 10 per cent, solution of Burow's mix- 
ture rnay be applied as described above. 

After thus softening aiul removing the horny layer, the parts should 
l)e painted with a 10 to 20 per cent, solution of the nitrate of silver. The 
author has used this method after the suggestion of Politzer, with the 



636 THE EAR 

greatest satisfaction. An immediate cure should not be expected, as 
several weeks are often necessary to effect it. 

Fissures or cracks at the external auditory orifice are best treated Avith 
solid nitrate of silver or salicylic acid ointment. 

Nearly all the ointments in the Pharmacopoeia have been used in 
eczema, but further mention of them need not be made here. If the 
treatment according to the above principles fails, the case is probably 
one which will resist all treatment. In the event of failure take espe- 
cial care to thoroughly soften the scaly epidermis and to remove it, and 
then use the silver solution again. INIany of the failures are due to the 
non-observance of this procedure. 



CHAPTER XXXVIIL 

MALFORMATIONS AND DISEASES OF THE MEMBRANA TYMPANI. 

In early life the upper portion of the membrana tympani may be absent, 
with no history of previous suppuration. This is explained by the fact 
that in the embryo this is the last portion of the membrane to form, and, 
the process not being complete, a perforation or opening persists. Von 
Troltsch suggested that some of the perforations just above or behind the 
processus brevis mallei, such as are seen in otorrhea, are congenital, 
becoming enlarged by a subsequent suppuration within the tympanum. 
This observation may be questioned in certain particulars in view of the 
fact that the location of the perforation is usually indicative of the char- 
acter and seat of the middle-ear involvement. For instance, a perfora- 
tion in the region of the processus brevis mallei usually indicates a necro- 
sis of the malleus, and possibly, also, of the tegmen tympani. We find 
that the perforation appears as readily in other portions of the membrana 
tympani if the focus of the middle-ear lesion is in other locations. Never- 
theless, it may be said that a certain number of perforations in the region 
of the short process of the malleus may be of congenital origin, and 
that this portion of the membrana tympani is thereby rendered more 
vulnerable. 

INJURIES OF THE MEMBRANA TYMPANI. 

While injuries to the membrana tympani are comparatively rare, 
nevertheless, when they do occur it is important to know the proper 
method of procedure. They may be due to either direct or indirect 
violence. 

Etiology. — Injuries hy direct violence may be due to (a) attempts to 
remove the cerumen from the meatus with a pin, a hairpin, a toothpick, 
an earspoon, etc.; (6) the accidental thrust of any long slender instru- 
ment, tool, or splinter of wood; (c) the introduction of a caustic or a hot 
fluid into the meatus; {d) the fracture of the bone supporting the mem- 
brana tympani; (e) and, finally, sneezing, inflation of the ear, etc., may 
also rupture the membrana tympani. 

Injuries hy indirect violence may be due to (a) the violent and sudden 
compression of air in the meatus by a blow on the ear with the palm of the 
hand, or it may be due to (/;) the concussion of the atmosphere during a 
violent explosion or discharge from a large camion. In view of the more 
or less familiar occurrence of windows ])eing l)lown inward at the 
time of an explosion, it niay be readily apj)recia ted how the membrana 
tympani may be ruptured by such an atmospheric disturbance. 



638 THE EAR 

Sjnnptoms. — Pain is a prominent symptom in those cases in which 
there is severe reactionary inflammation, while it may be absent if there 
is little or no inflammation following the injury. In some the pain is 
only present at the time of injury. Hemorrhage, more or less severe, 
may immediately follow the injury, or in rare cases it may continue for 
an indefinite period. Faintness, giddiness, staggering gait, convulsions, 
and nausea characterize those cases in which the foot plate of the stirrup 
is forced inward, and in which the trauma irritates or otherwise injures the 
labyrinth. The loss of hearing may be partial or complete and temporary 
or permanent. The tinnitus at first appears as a loud noise, and then 
subsides until it is only moderate in severity or entirely disappears. The 
effects upon the hearing are various. Deafness may be so pronounced 
that the watch can only be heard by contact, or, on the contrary, the 
patient may suffer from hyperesthesia acoustica. When the labyrinth 
is injured the deafness may be pronounced or absolute. If the injury 
involves the semicircular canals, the equilibrium may be disturbed for a 
few days or weeks. 

If the injury occurs in an ear in which the drumhead is adherent to 
the promontory, it may overcome the adhesions and thus affect the 
hearing favorably. In some cases the sense of direction of tones is 
lost, while in others there is simply a sense of fulness in the ears. 

The rupture is usually located in the postinferior quadrant of the 
membrana tympani, the periphery not usually being involved, as the 
membrane is thicker and firmer near its border. The appearance of the 
rupture is usually a mere slit (dark line), varying in extent and shape. 
In other cases it may appear as a round perforation with ecchymotic 
spots scattered over the membrane. If the injury is inflicted by a blunt 
instrument the perforation is irregular or ragged in outline. 

Cases have been reported in which there was an escape of cerebro- 
spinal fluid from the ear, the foreign body having entered the labyrinth. 
The fluid may also escape into the middle ear when there is a fracture 
through the petrous portion of the temporal bone. 

The ossicles of the middle ear, more particularly the malleus, 
are sometimes fractured. While the fractured parts reunite, they do 
not usually do so in their normal position. The author once saw a case 
in which the handle of the malleus was fractured about 1 mm. below 
the short process, the parts reuniting in nearly or quite their normal 
position. 

Prognosis. — The prognosis is usually good, as the injury ordinarily 
consists of a simple laceration or perforation of the membrane. In those 
cases in which the labyrinth is involved the prognosis should be guarded. 
If the injury to the labyrinth consists of a perforation of its outer wall, a 
good result may be expected after the lapse of a few weeks. The giddiness 
and nausea may persist for one or more weeks. If the osseous walls of 
the middle ear are fractured, or if the ossicles are injured, the hearing may 
be permanently impaired. Should purulent inflammation complicate 
the case, the prognosis becomes more grave. The functional tests of 
hearing should be used in all cases of fracture or injury, as by them the 



INFLAMMATION OF THE MEMBRANA TYMPANI 639 

surgeon is enabled to draw conclusions as to the extent and location 
of the injury and as to the probable outcome of the case. 

Treatment. — In nearly all cases no treatment should be used other 
than the introduction of a cotton or gauze tampon into the meatus to 
prevent infective matter entering through the wound. If, in spite of this 
simple precaution, marked inflammatory symptoms develop, leeches 
should be freely applied over the mastoid region and in front of the tra- 
gus, to promote the reaction of inflammation and thus aid in destroying 
the bacteria. Great care should be exercised in the treatment of these 
cases lest infection be carried into the wound and the case become compli- 
cated by suppurative inflammation of the middle ear and mastoid cells, 
hence meddlesome treatment is to be condemned. 



MYRINGITIS; INFLAMMATION OF THE MEMBRANA TYMPANI. 

Etiology. — Myringitis may be primary or secondary. The primary 
form is rare, and when present it is usually due to an injury by a foreign 
body, instrumentation, or the introduction of caustic fluids into the 
meatus. Secondary inflammation of the membrana tympani is more 
common, and is due to an extension of an inflammatory process from the 
auditory meatus or the cavum tympani. Thus, in the various forms of 
dermatitis and acute otitis media catarrhalis it is often present. 

Symptoms. — The chief symptoms are pain, more or less severe in 
character, with a slight rise in temperature. Deafness and tinnitus are 
present in proportion to the local injury and the swelling of the mem- 
brana tympani and the nature of the associated middle ear disease. 

Objective Symptoms. — The membrana tympani is usually most 
affected in its upper portion and especially along the line of the handle 
of the malleus. In this region it is yellowish red in color, from the con- 
gestion present. In a few days or hours the handle is lost to view, owing 
to the intense congestion and infiltration of the membrane, the upper 
portion of which bulges outward into the canal. The epidermic layer 
may become separated from the fibrous or middle layer of the eardrum 
l)y the serous or seropurulent fluid which accumulates between them. 
Blisters or blebs sometimes form. The inflammatory process may involve 
the osseous portion of the canal and thus obliterate the line of demar- 
cation between the eardrum and the canal. 

The mode of tcrminatioti is by slow resolution, the signs of inflamma- 
tion often persisting for many weeks. In some cases faity degeneration 
or even calcareous deposits may be left in the wake of the disease. 

, Ih-srcis of the membrana tympani may occur in the course of an acu((> 
otitis media. The process is confined chiefly to the fibrous and the 
mucous meml)rane layers, in contradistinction to the blisters which may 
form under tlie dermic or outer layer. 

Vesicular or herpetic eruptions sometimes complicate myringitis, as 
referred to above. 

Ilemorrhac/ic eruptions similar to those described unch-r Otitis Externa 
Hemorrhagica are occasionally present. 



640 THE EAR 

Diagnosis. — The chief diagnostic point is to be found in the slight 
disturbance of hearing. The ear appears to be extensively and seriously 
involved, while the hearing is but slightly impaired. The appearance 
is much like that of acute suppurative otitis media, but the loss of hearing 
is slight as compared with that found in the latter disease. Moreover, 
in suppurative otitis media the drum membrane bulges more markedly 
into the canal. 

Prognosis. — The prognosis must be based upon a knowledge of the 
eitology of each case and upon the destructive or degenerative changes 
occurring in the membrana tympani. If the myringitis is due to a severe 
injury, or if fatty degeneration and calcareous deposits are in the 
substances of the membrana tympani, the prognosis is less favorable than 
when the case is simple in origin and of slight severity. On the other 
hand, if perforation takes place and chronic suppurative otitis media 
supervenes, the prognosis is still more unfavorable. 

Treatment. — The treatment is (a) general, (b) local, and (c) surgical. 
The general treatment should consist in the administration of tonics, 
the iodides, and cod-liver oil if the patient is the subject of any of the 
dyscrasias; saline cathartics should also be administered. The local 
treatment should consist of the application of natural or artificial leeches 
to the mastoid process, to increase the hyperemia and leukocytosis, i. e., 
promote the reaction of inflammation. The instillation of solutions of 
cocaine are advised, but are of doubtful utility unless used in the 
following combination : 

I^ — Cocaine hydrochloratis, 
Menthol crystals, 

Carbolic acid crystals, aa 5J — M. 

Sig. — One or two drops in the fundus of the auditory meatus will relieve the pain in from 
five to fifteen minutes. 

The parts are at the same time anesthetized and prepared for the 
opening of the abscess in the membrana tympani if it is present. The 
remedy should be used with some caution, as it is liable to be absorbed 
in sufficient quantity to cause toxic symptoms. The instillation of alcohol 
into the meatus dilutes the solution and facilitates its removal if it should 
become necessary. 

The surgical treatment should consist in the incision of the outer or 
dermic layer of the membrana tympani. In those cases complicated by 
abscess care should be exercised to avoid perforating the inner layer, 
as infection might thus be carried to the middle ear. Gruber recom- 
mends making incisions in the osseous portions of the auditory meatus 
near the membrana tympani. The incisions should be about | inch long 
and parallel with the circumference of the drumhead, so as to incise the 
arterial branches at its circumference. The hemorrhage thus induced 
promotes the reaction of inflammation and favors resolution. 

After the abatement of the acute stage a serous discharge is given 
off from the membrana tympani and the painful symptoms subside. 
The ear should now be irrigated with a warm boric acid solution, dried, 
and the meatus closed with absorbent cotton. 



PERFORATION OF THE MEM BR AN A TYMPANI 641 

The cavum tympani (middle ear) may be inflated by the PoHtzer 
method, the diagnostic tube being used to determine if a perforation 
is present. The membrana tympani should also be inspected for the 
same purpose. If a perforation is present the diagnostic tube conveys 
the whistling sound characteristic of a perforation to the examiner's 
ear. The membrana tympani may be so swollen that the perforation 
cannot be seen. The pus discharging into the meatus is another index 
as to the presence of a perforation. This is rendered all the more prob- 
able if the discharge contains strings of mucus. The presence of a per- 
foration and chronic otitis media render the prognosis more serious. 



PERFORATION OF THE MEMBRANA TYMPANI; ULCERATION OF 

THE DERMIC LAYER; CHRONIC MYRINGITIS; CHRONIC 

INFLAMMATION OF THE DRUMHEAD. 

Etiology. — The causes leading to perforation of the membrana tympani 
may be either external or internal. One of the external causes is acute 
myringitis, with local fatty degeneration and subsequent sloughing of the 
substance of the drumhead, the degenerative process beginning with the 
outer layer and extending inward. Another external source is acute 
dermatitis of the external meatus. This may extend to the drumhead and 
result in the same degenerative and perforative process. In many in- 
stances the fatty degeneration is not followed by perforation, calcareous 
changes occurring instead. 

In some cases the destructive process is limited to a simple ulceration 
of the dermic layer, which may appear as a simple circumscribed 
roughness of the surface or as a reddened area where the epidermis is 
removed. 

The internal causes of perforation or chronic inflammation are either 
the acute catarrhal or the acute suppurative forms of otitis media. The 
mucous layer of the drumhead first undergoes the ulcerative process, 
the fibrous and the dermic layers giving way at subsequent periods. 
The membrana tympani may long remain the seat of chronic inflamma- 
tion, the bloodvessels being injected and radiating from the margins of 
the ulceration or perforation. 

Symptoms. — If the lesion is simple — a superficial dermic ulcer — the 
symptoms are slight, tinnitus and a moderate disturbance of hearing 
being present. If the ulcer is phlegmonous in type, pain and increased 
deafness are present. The secretions and the exfoliation of epidermis 
form crusts on the surface of the membrana tympani and obscure the 
real lesion until they are removed. Granulations may spring from 
the bottom of the ulcer. 

In those cases in which there is perforation the tinnitus and the deaf- 
ness arc more pronounced. If the middle-ear cavity is Jiot primarily 
infected, it l)ecomes so through the perforation. Pus is discharged 
through tiie opening into tlie exteriuU auditory meatus. If the ear is 
inflated by the Valsalva, the Politzer, or the catheter method, a whistling 
-11 



642 THE EAR 

noise may be heard through the diagnostic tube. Inspection, after 
removing the debris from the auditory meatus, usually reveals the per- 
foration. It is often oval, though it may be round, pear- or kidney-shaped. 
Its location generally indicates the focal centre involved within the 
middle ear or the accessory mastoid cavities. 

Course. — The duration of chronic inflammation of the membrana 
tympani, with or without perforation, is usually quite prolonged. The 
dermic layer often undergoes repeated or continuous desquamation, 
or there may be foci of fatty degeneration with calcareous deposits. In 
some cases there is an atrophic process which renders the membrane 
thin and parchment-like, its function being thereby impaired. In still 
other cases of external origin perforation occurs, and is followed by infec- 
tion and suppuration within the middle ear. This may continue indefi- 
nitely, or until ulceration and necrosis of the bony walls of the middle 
ear and the pneumatic spaces of the mastoid process occur. 
J Treatment. — In those cases in which there is an active desquamation 
or dermic ulceration, the crusts should be softened with a warm solution 
of bicarbonate of soda, and then removed by syringing with a warm 
solution of boric acid. The author's experience has justified the local 
application of a 10 gr. solution of the nitrate of silver or of the compound 
tincture of benzoin. The nitrate of silver stimulates healthy granulation 
and regeneration, and the compound tincture of benzoin is astringent and 
stimulates the process of repair. 

If perforation has taken place and thecavum tympani is not yet infected, 
an endeavor should be made to bring about regeneration of the membrana 
tympani, thus closing the perforation. This may be done by maintaining 
the external auditory meatus and the membrana tympani in an aseptic 
condition, stimulating applications being made to the margins of the 
perforations, with the view of favoring granulation at the margins of the 
perforation until the opening is completely filled in. Various devices and 
procedures have been employed for this purpose, the best one being 
the local application of a 20 per cent, solution of trichloracetic acid. 

For the treatment of the middle-ear complications see Suppurative 
Diseases of the Middle Ear. 



INCISION OF THE MEMBRANA TYMPANI. 

This mode of treatment is coming into vogue more than formerly, as 
clinical experience has demonstrated that when it is done at the proper 
time the attack of acute inflammation of the middle ear is aborted. Its 
effects are due to the promotion of the reaction of inflammation and the 
facility with which drainage of the tympanic cavity is accomplished. 
The presence of the inflammatory exudate within the cavum tympani is 
a source of irritation because of its chemical composition and on account 
of the pressure it exerts upon the swollen and inflamed mucous membrane. 
It is, therefore, important that free drainage be established at a very 
early period in the course of the disease. Formerly, it was recommended 



INCISION OF THE MEMBRANA TYMPANI 



643 



that simple puncture of the drumhead be made for this purpose. Hovell 
advocates this procedure. I cannot recommend so shght an incision, as I 
find that a free incision is attended by more immediate and better results. 
Little harm results from free incision of the membrana tympani, as 
union often takes place before it is desirable that it should do so. Even 
when union does not occur early, only a very slight amount of scar tissue 
is left behind. 




Right membrana tympani, showing the division into A, postsuperior quadrant; B, anterosuperior 
quadrant; C, antero-inferior quadrant; D, postinferior quadrant. 

.One should not wait until there is bulging of the membrana tympani, 
but should make an incision v^henever he finds there is marked redness 
and thickening. The membrana tympani may be so sv^ollen and red 
that the outline of the malleus cannot be distinguished. If the incision 
is delayed until bulging of the drumhead occurs, serious and extensive 
pathological changes may take place; whereas if it is done early the 




»r - —i:^s^mm 










rrt '^ - - 




1 1 1 




'^" 


X 





J'.ar instruments. 



progress of the disease is checked and the process of resolution is 
established. The incision increases hyperemia and leukocytosis, and 
tlius raises the resistance of the tissue and destroys the microorganisms. 
Tlie most suitable place for the incision is in the posterior inferior 
quadrant (Fig. 355), as this is generally the most accessible, owing to 
the curvature of the anterior wall of tlie external auditory meatus, whicli 
obstructs the view of the anterior portion of the membrana tympani. 



644 THE EAR 

The best instrument for this purpose is a curved bistoury (Fig. 356). 
The lance-shaped or the spear-pointed knives are not well adapted 
for this purpose, as they are made for simple paracentesis. The 
point of the knife should be introduced only far enough to penetrate 
the thickness of the membrana tympani, as to pass it deeper might 
subject the inner wall of the cavum tympani to injury. It should be 
remembered that the distance from the outer to the inner wall is only 
about -j^ to |- inch. The incision should be curved or V-shaped (Fig. 
357), so as to allow a wider opening between the lips of the incision. 
In this way free drainage is established. The incision should be from 
^ to I inch in length. 

Immediately after the incision a bead of viscid mucus may be seen 
protruding through it. The contents of the tympanic cavity are not dis- 
charged at once unless they are of a fluid natiu'e. To hasten the discharge 
of the viscid mucus, a solution of boric acid or bicarbonate of soda may 
be dropped into the meatus to liquefy it. 




Showing a long, curved incision through the membrana tympani for the evacuation of inflam- 
matory secretions. With such an incision the anterior flap is forced aside by the secretions as in- 
dicated by the dotted line, thus providing free space for drainage. A simple puncture or paracen- 
tesis as shown by the short line is inadequate and should not be practised. 

Previous to the incision the external auditory meatus should be 
cleansed with a 1 to 4000 solution of bichloride of mercury to render the 
membrana tympani and the auditory meatus sterile. Anesthesia of the 
membrana tympani may be obtained by dropping a small quantity of a 
solution composed of equal parts of hydrochlorate of cocaine, menthol, 
and carbolic acid into the auditory meatus. In from five to fifteen 
minutes complete anesthesia is produced, and the incision may be made 
with comparatively little or no pain. Complete absence of pain is not 
always obtained, however, as it should be remembered that the parts 
contiguous to the membrana tympani are often inflamed and sensitive. 

Immediately after the incision the auditory meatus should be dried 
with a cotton-wound applicator and then loosely packed with sterilized 
gauze. The end of the strip of gauze should be made to touch the incised 
portion of the drumhead, while the balance is placed loosely in the 
meatus. It should be left in place until it becomes saturated with 
the secretions, when it should be removed and a fresh one introduced. 



I 



INCISION OF THE MEMBRANA TYMPANI 645 

During the first two or three days it may be necessary to pack the meatus 
two or more times a day. The patient should be kept in bed during this 
time, as much more favorable and rapid progress may be made under 
such conditions. After the first few days it is not necessary to dress the 
meatus so often, once a day being quite sufficient. A Httle later every 
other day will be all that is necessary. The dressings should be discon- 
tinued when the discharge through the incision ceases and it has closed. 

After the incision is made the use of the syringe with any sort of solu- 
tion is not allowable, as infection may thereby be conveyed through the 
opening into the tympanic cavity. When the acute inflammation has 
somewhat subsided, inflation by the Politzer method through the Eus- 
tachian catheter should be performed, as the drainage is thus facihtated. 

Spontwieous perforation of the drumhead may take place in the course 
of the disease from softening of the tissues by maceration or from 
pressure necrosis. As already stated, this should be anticipated if possible, 
either by instrumental perforation of the drumhead or by one or more of 
the remedies which have been recommended. Should spontaneous per- 
foration occur the treatment instituted should be similar to that recom- 
mended after incision of the membrana tympani. 

Paracentesis is an almost obsolete from of incision, and is not given as 
synonymous with incision, as by the latter expression is meant a larger 
and more extensive opening in the drumhead than is implied by the 
former. By paracentesis is meant a mere puncture through the mem- 
brane with a double edged or spear-pointed knife. What follows, there- 
fore, refers to some form of incision and not to a mere puncture of the 
drumhead. 

The general purposes of incision of the membrana tympani are : (a) To 
relieve pain; (b) to establish drainage for excessive secretions (catarrhal 
and suppurative); (c) to open the middle ear for certain operations; 
(d) to relieve intralabyrinthine pressure; (e) to allow sound waves to 
reach the oval and round windows; and (/) to promote the reaction of 
inflammation. 

The indications for incision, as briefly outlined in the preceding para- 
graphs, may be amplified as follows: 

1. In otitis media with excessive secretion it may become necessary 
to make a free incision to prevent pressure necrosis of the drumhead and 
the tympanic mucosa. The secretion is often so thick and tenacious that 
it will not discharge through the Eustachian tube. Retention also causes 
pain and favors decomposition and infection. The incision also pro- 
motes the reaction of inflammation (see Inflammation), and thus favors 
speedy resolution. 

One should not wait until pronounced pain develops, bulging of the 
membrane being amj)le justiflcation for the procedure. Should pain 
persist without l)ulging, the incision should be made, as it promotes the 
reaction of inflammation and tiius favors resolution. 

2. In acute myringitis abscess formations sometimes occur l)etween 
the layers of the membrana tympani. They should be opened, care 
being taken not to open the inner or mucous layer. To open this exposes 



646 THE EAR 

the middle ear to the dangers of infection from the abscess. If the abscess 
is not evacuated in this way, there is danger of perforation of the inner 
layer and infection of the middle ear. 

Pearly gray blisters sometimes appear on the membrana tympani, and 
they should be pricked, for if left to discharge spontaneously the danger 
of infection is prolonged. 

Inflammation of the deeper layers with bulging and purplish swelling 
should be scarified to relieve the pain and the tension. Incisions through 
the entire thickness should not be attempted, for the reasons already 
stated. 

3. Tenotomy of the tensor tympani muscle is sometimes performed 
to relieve deafness and tinnitus. (See Tenotomy of the Tensor Tympani 
Muscle.) The preliminary step in the operation is an incision of the 
membrana tniipani. 

4. A thickened membi'ana t}aiipani from hyperplasia in chronic catar- 
rhal otitis media is often present; obstruction of the Eustachian tubes is 
also present. The rarefaction of the air within the t}anpanum gives rise 
to retraction of the membrana tympani and pressure upon the labyrinthine 
fluid by the foot plate of the stapes. The drumhead may be incised as a 
temporary measure, or a portion of the drumhead may be removed with 
a knife or cautery to admit air into the middle ear when the Eustachian 
tube is obstructed. All such measures have met with but partial or 
temporary success, the opening usually closing within a few days. 

The relief is often pronounced while the perforation remains open, 
but quickly disappears after it closes. 

Malherbe has written extensively upon what he terms "Evidement of 
the Mastoid," whereby a channel of communication between the tym- 
panic antrum and the external acoustic meatus is established, thereby 
permanently overcoming the disturbance due to the closure of the 
Eustachian tube. 

5. In acute catarrhal otitis media attended by pain, bulging, and 
marked inflammatory infiltration, incision or scarification is often indi- 
cated to promote the reaction of inflammation and to establish drainage. 
If there is persistent pain with or without bulging of the membrana 
tympani, incision is indicated. The relief which follows may be due 
to the hemorrhage, for in many cases there is no discharge of secretions 
for several hours after the incision, though it is more probably due to 

■"the promotion of the reaction of inflammation. (See Inflammation.) 

When there is a livid, boggy appearance of the membrane it should be 
freely scarified, limiting the incisions to the outer layer. Circumscribed 
red spots sometimes appear in the course of the disease. They should be 
opened to hasten the process of resolution. 

The most bulging portion of the membrana tympani may appear 
yellowish green in color, even though the secretion is but little admixed 
with pus. Free incision should be made to establish drainage and to 
relieve the pressure necrosis which is beginning on the inner surface of 
the membrana tympani. 

6. Acute suppurative otitis media affords the most common opportu- 



INCISION OF THE MEMBRANA TYMPANI 647 

nity for incision of the membrana tympani, although it is often postponed 
until volmitary rupture occurs. The presence of pus within the middle- 
ear cavity when the drumhead is still intact is an imperative mdication 
for incision. It is not necessary to wait for pain and bulging of the mem- 
brana tympani; in fact, it is culpable negligence to do so, as every hour 
adds to the destruction of tissue. Incise the membrana tympani at once 
when the presence of pus is suspected in the middle ear, as it is of the greatest 
importance to promote the reaction of inflammation to combat the bac- 
teria and their toxins. 

The perforation in acute suppuration is usually small, hence it should 
often be enlarged by radiating incisions toward the periphery (Fig. 358). 

Persistent pain without bulging or profuse discharge of pus is an indi- 
cation of retained pus within the antrum and mastoid cells. The incision 
in these cases should include the pars flaccida (Shrapnell's membrane), 
so as to afford a direct outlet from the attic and to increase the reaction 
of inflammation. 




Showing two perforations of the membrana tympani and the incisions for facihtating drainage 
through them. The incisions should extend at an angle to the axis of the perforation so as to form 
movable flaps, which may be pushed aside by the secretions. 

7. Adhesive processes in the middle ear sometimes give rise to condi- 
tions which can be more or less relieved by incising the membrana tym- 
pani. The adhesive process may interfere with the vibratory action of the 
ossicles without the foot plate of the stapes being ankylosed. The open- 
ing in the drumhead admits sound waves into the tympanum where 
they strike the foot plate of the stapes, and fairly good hearing results. 
The tinnitus which is associated with the deafness is also relieved to some 
extent. As it is not practicable to maintain the opening for any con- 
siderable length of time, the procedure has almost fallen into disuse. 

Calcareous deposits in the membrana tympani are often found associ- 
ated with adhesive processes. They act as foreign bodies and impair 
the vibratory function of the membrana tympani, and an opening, as 
above stated, admits sound waves directly to the oval window. Besides 
this, the equili])rium of air pressure is thereby established and the pressure 
on tlie labyrinth by the ossicles is somewhat lessened. 

Through the opening it is sometimes possible to sever fibrous bands 
which extend from the malleus and incus to the walls of the tympanum. 
While the beneficial effects thus obtained are not long continued, the 



648 THE EAR 

temporary relief is marked and extremely gratifying to the patient. They 
are much depressed in spirits, and the temporary respite adds to their 
happiness. It should be frankly explained that the beneficial result will 
in all probability not be permanent. 

8. Atrophy and relaxation of the membrana tympani from too fre- 
quent inflation or other causes may be improved by light scarification 
with a sharp-pointed bistoury. Only the outer and the middle layer 
should l)e cut through. In this way scar tissue and blood supply will be 
increased, and the tension and tone of the membrane raised, with benefit 
to the hearing. 

9. Exploration of the middle ear and the attic sometimes becomes 
necessary in chronic suppuration. This is best done when the opening 
in the membrana tympani is high, as the roof or tegmen is usually 
necrosed. If, therefore, the perforation is small or in the lower portion 
of the drumhead, it may be necessary to extend it by incision in an 
upward direction. Having done this a small curved ear probe may be 
introduced into the attic for exploratory purposes. 

Preliminary examination of the function of hearing should be made 
before incising or removing a portion of the drumhead to improve hearing 
in adhesive processes of the middle ear. Unless bone conduction for 
the watch and the c^, 512 v., fork is good, but slight improvement will 
follow the operation. 

The middle and the lower portion of the posterior half of the membrana 
tympani is less sensitive than the upper portion, the sensitiveness gradu- 
ally increasing as the upper limit is approached. Blake takes advantage 
of this fact and punctures the membrane in its least sensitive area, then 
applies cocaine to the cut surfaces, waits a few minutes, and extends the 
incision slightly upward, applies more cocaine, and so on until the 
incision is extended the desired length. 

He also recommends the injection of a 2 per cent, solution of cocaine 
through the Eustachian catheter into the middle ear, as a means of pro- 
ducing anesthesia of the membrana tympani in middle-ear operations. 

Dupuy recommends the following mixture as a reUable local anesthetic 
in eardrum and middle-ear operations : 

I^ — Aniline oil, 

Alcohol aa 3J 

Cocaine hydrochlorate gr. vj — M. 

Sig. — Drop into the meatus and middle ear. 

This mixture does not always produce local anesthesia, as in a number 
of cases it has failed in my hands, notably in aural polypi. 

]\Iore or less cyanosis occasionally attends its use, hence it should be 
used with caution. 

The following mixture is more reliable and less dangerous : 

I^ — Cocaine hydrochlorate, 

Menthol crystals. 

Carbolic acid crystals aa 3J — M. 

Sig. — Drop into meatus or middle ear, and in twenty minutes anesthesia is complete. 



I 



INCISION OF THE MEMBRANA TYMPANI 649 

Methods of Operating, — The electrocautery may be used in adhesive 
non-inflammatory cases. The opening thus made persists longer than 
one made with a knife. The points to be observed are the following: 

(a) Preliminary local anesthesia should be produced by the injection 
of a 2 per cent, solution of cocaine into the middle ear through a 
Eustachian catheter or the above formula may be used. 

(b) The electrode should be a simple straight, pointed one with the 
shank so bent that the electrode handle and the hand of the operator 
will not obstruct the view. 

(c) The current should be turned on until the point is instantly raised 
to a bright-red heat. If the platinum point heats too slowly the adjacent 
parts may be injured by the radiation of heat. The pressure exerted by 
the electrode should be sHght, as otherwise there is danger of injuring 
the mucous membrane of the inner tympanic wall. 

(d) Contact should be made with the drumhead before the electric 
current is turned on. 

(e) Usual time of heat contact, one second. 

Incision with a Lancet. — Preference should be given to Hartman's 
curved lancet (Fig. 356), the spear-pointed instruments formerly used 
being of little value except for simple puncture. 

The most favorable or available location for incision in adults is the 
posterior half of the drumhead. In children the external meatus is 
shallow and straight, so that all portions of the drumhead are accessible. 

Other things being equal, the most bulging portion (fluid being present) 
should be incised, because it is the point of least resistance and because 
the parts are not so sensitive in this area. Indeed, if bulging is pronounced, 
the incision can often be made without the use of a local anesthetic. 

The length, direction, and character of the incision should depend upon 
the purpose for which it is made. If it is done to establish free drainage, 
it should be long and curved, or angular (Fig. 359) . If it is to expose the 
contents of the middle ear, as for operations upon adhesive bands and 
upon the stapes, the incision recommended by Blake (Fig. 360) should be 
made. If it is for the purpose of admitting air to the middle ear, a round 
or triangular opening may be made. The cautery is well adapted for this 
purpose. If it is done preliminary to tenotomy of the tendon of the tensor 
tympani, or for plicotomy, a short straight incision (Fig. 361) is all that 
is necessary. 

Postoperative Considerations. — (a) When the incision is made to 
evacuate mucus or mucopus, a pulsation synchronous with swallowing 
and articulation will occur at the point of incision. Pus and mucus 
rarely appear immediately after the incision. This is quite disconcerting 
to the inexperienced aurist, as he may have unwittingly promised an 
immediate evacuation of the secretions. A little experience will, however, 
convince him that on account of the thick and adhesive character of the 
secretions they will only appear several hours after the incision is made. 
The expulsion of the secretions can be hastened by instilling a warm 
solution of bicarbonate of soda into tlie middle ear. The soda over- 
comes the adhesive property of the mucus and therei)y facilitates its 
(lischarire. 



650 THE EAR 

Sometimes the mucus is so thick and tenacious that it can be seized 
witli forceps and thus removed. It may also be removed by suction with 
the Delstanche masseur. 

(h) Closure of the incision in non-suppurative cases usually occurs in 
from one to three days. In suppurative cases it may remain open a few 
days or be indefinitely prolonged. 




Fio. 359. — Showing a long, curved incision of the membrana tympani extending into the superior 
wall of the meatus (white line). As there is a plexus of bloodvessels around the margin of the 
membrana tympani greater reaction of inflammation is produced by extending the incision through 
it, hence the improvement of the inflammation is more prompt than in simple incision of the 
membrane. (See Reaction of Inflammation.) 

Fig. 360. — Incision for stapedectomy, showing the inendostapedial articulation. The stapedius 
muscle should be severed to prevent the dislocation of the stapes, the inendostapedial articulation 
broken, and the stapes removed from the oval window. This operation is rarely justifiable. 

Fig. 361. -^Showing an incision through the posterior fold of the membrana tympani to relieve 
the tension of the membrane in adhesion processes. 

(c) The dressing should consist of a strip of sterilized gauze placed 
loosely in the meatus but touching the drumhead. If the discharge is 
profuse a pad of the gauze may be placed over the auricle and held in 
position by a bandage. The meatus and the auricle should first be 
cleansed with a 1 to 3000 bichloride solution before introducing the 
gauze dressings. 



CHAPTEE XXXIX. 

THE DISEASES OF THE EUSTACHIAN TUBES. 

THE RELATIONSHIP OF THE EUSTACHIAN TUBES TO HEARING 
AND MIDDLE-EAR DISEASES. 

The Eustachian tube is the chief source of communication between 
the epipharjnx and the middle ear. Through it the tympanic cavity 
is ventilated and the normal tension of the drumhead and the ossicular 
chain is maintained, thereby facilitating the transmission of sound 
waves to the internal ear. The pharyngeal end of the tube is supported 
by cartilage, while the tympanic end has an osseous framework. At 
the union of the cartilaginous and the osseous portions the tube becomes 
narrow, forming what is known as the isthmus. The throat end is 
subject to the diseased processes peculiar to the epipharynx, while the 
tympanic end is affected by the changes peculiar to the tympanic cavity. 
In other words, the throat end is subject to pronounced catarrhal and 
suppurative inflammations and to hypertrophy of the lymphoid tissue 
lining the mucous membrane, and the tympanic end to catarrhal and 
adhesive changes in addition to the suppurative process. The adhesive 
process is, therefore, chiefly found in the less accessible portion of the 
tube — namely, beyond the isthmus, and consequently difficult to reach 
with electrolytic bougies or those used for the purposes of simple dilata- 
tion. 

The relationship of the Eustachian tube to the diseases of the tympanic 
cavity is twofold — namely: (a) Obstruction of its lumen by catarrhal 
congestion, hypertrophy, cicatricial contraction, and mucous plugs; and 
(b) as an avenue through which infective material may gain entrance 
to the middle ear. The obstructive lesions or accumulations prevent the 
proper ventilation of the tympanic cavity, and the contained air becomes 
rarefied through gradual absorption of the oxygen, thus causing retrac- 
tion of the drum membrane and engorgement of the bloodvessels of the 
mucous membrane. 

The retraction of the drumhead increases the tension of the ossicular 
chain, and interferes with the normal transmission of sound waves 
to the labyrinth. Tinnitus and deafness thus result. The obstruction 
to drainage lowers the resistance of the tissues and predisposes to infec- 
tion and inflammation. 

Infectious material may gain entrance into the middle ear during 
acts of yawning, coughing, sneezing, or swallowing. The tube is 
lined with ciliated columnar epithelium, having a wave-like motion 
toward the pharyngeal orifice. In the healthy state it is not probable 



652 THE EAR 

that bacteria travel toward the middle ear on the mucosa. If, however, 
the catarrhal inflammation of the lining membrane of the tube is severe 
or prolonged, the epithelium may lose its cilia, and it is not improbable 
that germs do sometimes reach the middle ear without the tube being 
opened by the acts of coughing and sneezing. 

2'ubal tonsils, or hypertrophy of the lymphoid tissue in the mucous 
membrane of the cartilaginous portion of the tube is another possible 
source of obstruction. A study of the histology of this structure shows 
lymphoid tissue to be present in considerable quantity, and it is more 
than probable that hypertrophy of this tissue is often responsible for tidjal 
and middle-ear disturbances heretofore ascribed to catarrhal or other 
diseases. 

TUBAL CATARRH; CATARRHAL INFLAMMATION OF THE 
EUSTACHIAN TUBE; SALPINGITIS. 

Etiology. — Owing to the intimate anatomical connection of the 
mucous membrane of the Eustachian tubes with that of the epipharynx, 
it is easy to understand why they are usually involved in the course 
of an attack of epipharyngeal inflammation. If the epipharyngitis is 
chronic in character, the tubal disease is likewise chronic. ^Vhile tubal 
catarrh is usually secondary to a like process in the epipharynx, it is 
not always so, especially in children, in whom it is sometimes primary. 
In young children the pharyngeal orifice is narrow and easily retains 
the secretion and foreign matter. For this reason local inflammation 
may occur in the tubes independently of the epipharynx. 

Adenoid growths are often associated with a chronic epipharyngitis, 
which extends by continuity of tissue to the tubes. The adenoids do 
not often afford a mechanical obstruction to the patency of the tubes, 
as they grow from the posterior and superior walls of the epipharynx, 
and, therefore, do not involve the regions of the Eustachian orifices on 
the lateral walls. In some instances, however, they overlap the mouths 
of the tubes and thus obstruct them. Tuberculosis may be associated 
with adenoid growths and predispose to tubal inflammation. 

Pathology. — Congestion and round-cell infiltration characterize 
the early and acute stages of the disease. At a later period the epi- 
thelial covering becomes thickened, and fibrous tissue is deposited in 
the subepithelial layers. Hypertrophy of the mucous membrane occurs 
when the inflammation continues for a long time. If the inflammation 
is severe or prolonged the cilia are exfoliated, thus leaving the mem- 
brane denuded in places. The catarrhal inflammation may extend 
to the middle ear, although it has a tendency to limit itself to the 
pharyngeal or cartilaginous portion of the tube. 

Symptoms. — The subjective symptoms are a feeling of fulness in 
the ears, which may be constant or intermittent, accompanied by certain 
subjective noises and deafness. Pain is not usually severe, although it 
may be if the inflammation is pronounced. If there is marked retraction 
of the drumhead, giddiness and nausea may be complained of. The 



TUBAL CATARRH 653 

sense of deafness is often out of proportion to the actual deafness. The 
patients apply for relief with the statement that the external canal is 
filled with cerumen. During mastication and swallowing they often 
experience marked, though brief, relief from the symptoms. This is 
explained by the incidental, but incomplete, ventilation of the tympanum 
during the act of swallowing. Upon posterior rhinoscopy the mucous 
membrane of the epipharynx and the Eustachian orifices appears red- 
dened, swollen, and covered with a thick mucous secretion. The mouths 
of the tubes are contracted by the swollen membrane, and may contain 
a thick, tenacious mass of mucus. If adenoids are present, the furrows 
between the lobules are more or less filled with a slimy secretion admixed 
with pus. The ethmoidal and sphenoidal sinuses may also be the seat 
of inflammation. With good illumination it is possible to see the 
enlarged and tortuous bloodvessels in the inflamed area. 

The drumhead is more or less changed in its position and appearance 
by the rarefaction of the air in the tympanic cavity. It is more cupped, 
the handle of the malleus is foreshortened, and the short process and the 
posterior fold extending from it are more prominent. The angle 
formed by the handle of the malleus and the posterior fold becomes 
more acute with the increased retraction. The cone of light is diminished, 
broken, or altogether wanting. If the drumhead is extremely retracted, 
the promontory and the longprocess of the incus become visible through it. 

Prognosis. — The prognosis is good in those cases in which adenoid 
growths are removed, especially in children. It is also good in the early, 
or congested stage of the simple catarrhal type. In the hypertrophic 
stage it is not so good, as the obstruction is more permanent in character. 

Treatment. — The treatment of tubal catarrh should be largely 
addressed to the antecedent nasal and epipharyngeal conditions. If 
there is pronounced nasal catarrh, sinuitis, nasal obstruction, or epi- 
pharyngitis, it should receive appropriate treatment; likewise adenoids 
should be removed. Removal of the adenoids is usually followed by 
pronounced and immediate relief. Having corrected the nasal and 
the epipharyngeal disorders, the tubal inflammation often subsides 
without further treatment. Such a favorable result does not always 
follow, however, especially if the mucosa has become hypertrophic or 
hyperplastic in character. In many cases there is a mixture of turges- 
cence and hypertrophy, local medical applications only being capable 
of removing the congestion and limiting the further development of 
the hypertrophic process. 

Perhaps the most useful mode af applying remedies to the vault of 
tiie pharynx and the Eustachian orifices is in gargling after the von 
'JVoltsch method. The patient should lie on his back while gargling to 
allow the fluid to enter the epi[)harynx. This is not (Hfficult, as the head 
can be turned to one side in taking the fluid into and in ejecting it from 
the mouth. liy following this method of gargling the wiiole of the epi- 
pharynx, inchuHng the Eustachian orifices and the luisal chanil)ers, may 
l)e subjected to the influence of astringent and antiseptic remedies, with 
very favorable results. The deafness and tinnitus are often relieved. 



654 THE EAR 

The injection of from 1 to 4 minims of weak astringent solutions 
into the Eustachian tubes through a catheter is recommended. Care 
should be taken to avoid injecting it into the middle ear, as reactionary 
inflammation might follow. The syringe should be so gauged as to fill 
the catheter and leave a surplus of from five to ten minims. The extra 
solution is to allow for the inevitable escape of fluid into the epipharynx. 
The nose and the epipharynx should be sprayed with a 2 per cent, solu- 
tion of cocaine to reduce the sensibility of the parts before introducing 
the catheter. The solutions most often used are (a) the iodide of 
potassium, 10 gr. to the ounce; (b) the bicarbonate of soda, 3 to 5 gr. 
to the ounce; (c) the sulphate of zinc, 1 gr. to the ounce; and {d) the 
nitrate of silver, 2 to 5 gr. to the ounce. 

Various vapors of iodine, ammonia, menthol, camphor, eucalyptol, 
etc., have been recommended. Iodine and ammonia are readily vola- 
tile, and the fumes therefrom may be sufficiently generated in a Buttles- 
Pynchon inhaler, as shown in Fig. 362. The inhaler should be connected 
with the catheter and air forced through it into the Eustachian tube. 




Buttles-Pynchon inhalei'. 

A piece of sponge or cotton should be moistened with the desired solution 
and placed in the chamber of the inhaler. Another way of using the 
vapors of the foregoing drugs, either singly or in combination, is with 
a nebulizer. Either the nebulizer may be attached to the Eustachian 
catheter, or the vapors may be driven into the middle ear by the 
modified Politzer method, in which the nebulizing device takes the 
place of the rubber bag used by Politzer, the balance of the procedure 
being done according to the directions given under the Politzer method 
The author has often put a few drops of the desired volatile solution into 
the Politzer bag and then practised inflation in the usual manner, the 
fumes being carried into the tubes and the middle ears. 

The value of the foregoing topical remedies does not consist alone of 
the medicinal properties of the drugs, but includes the mechanical 
eft'ects of inflation. The current of compressed air directed into the 
orifice of the Eustachian tube removes the secretions and temporarily 
unloads the congested vessels and establishes normal glandular activity. 

The principles to be observed in the treatment of tubal catarrh may be 
summarized as follows: 



OBSTRUCTION OF THE EUSTACHIAN TUBE 655 

{a) The correction of obstructive nasal lesions, and of inflammatory 
diseases of the nose and accessory sinuses. 

(h) The removal of neoplasms and inflammatory conditions in the 
epipharynx. 

(c) The topical application of antiseptic, astringent, and stimulating 
remedies to the mucosa of the Eustachian tubes. 

(d) The mechanical efl^ects of inflation. 

(e) The administration of remedies to give tone and vigor to the 
general system. 

It should be said, in reference to the latter principle, that in many 
cases of deafness from tubal catarrh the administration of tonics and 
other constructive remedies is often followed by an improvement in 
hearing. This is especially true in those cases in which there is no pro- 
nounced nasal or epipharyngeal disease to account for the trouble. It 
is usually best to begin the treatment with a 2 to 3 gr. dose of calomel 
at bedtime, followed by a saline cathartic the following morning. After 
this, laxative doses of cascara may be given twice daily. The patient's 
alimentary tract is thus kept in a condition to care for and distribute the 
constructive remedies. These remarks are equally applicable to all the 
catarrhal afl^ections of the upper respiratory tract. 

The Relation of the Eustachian Tube to Mastoiditis. — The 
Eustachian tube is adequate to drain all secretions from the middle ear, 
but it is often inadequate to drain the combined secretions of the middle 
mastoid antrum and cells, hence retention, pressure necrosis, and all 
the phenomena peculiar to mastoiditis. If the secretions from the 
antrum and mastoid cells are diverted from the middle ear, the Eus- 
tachian tube effectually drains the middle ear, and the diseased process 
rapidly improves. (See Heath's Mastoid Operation.) 



OBSTRUCTION OF THE EUSTACHIAN TUBE. 

Partial Obstruction.— Etiology.— Obstruction of the Eustachian tube 
may be due to a variety of conditions, namely: (a) Hypertrophy of 
the mucous membrane, especially that in the pharyngeal or cartilagi- 
nous portion, the hypertrophy being an extension of the same process 
from the nose and the epipharynx. (/;) Repeated inflammations, 
giving rise to a hyperplastic thickening and consequent obstruction. 
(c) Adhesive bands or constrictions forming in either the tympanic or 
the j)baryngeal end of the tube, especially if the same pathological 
process is going on in the tympanic cavity, {d) Syphilis, tuberculosis, 
and diphtheria at the pharyngeal orifice, causing cicatricial contractions 
which more or less ol)struct the opening, {e) Adenoids, while they do 
not grow from the Eustachian orifice, may be so large as to overlap 
and thus close it. (/) Paralysis of the palatal muscles from diphtheria 
and mixed infection, or from degenerative changes of the muscular 
fibers from repeated inflammations coincident witli tonsillar inflannna- 
tion, giving rise to collapse of the muscular and other soft tissue at the 



656 THE EAR 

pharyngeal orifice and thus causing its occhision. (g) Adhesions of 
the posterior pillars to the tonsils by interfering with the muscular move- 
ments contribute to the collapse of the Eustachian orifices, {h) Certain 
anatomical features give rise to obstruction, as exostoses and hyper- 
ostoses of the walls of the tubes; there may be a sudden bend in the 
direction of the tube, or the carotid canal may encroach upon it and 
thus o])struct it. 

Diagnosis. — The diagnosis may be made by observing the charac- 
teristic retraction of the drumhead, foreshortening of the handle of 
the malleus, and the prominence of the short process and the posterior 
fold of the tympanic membrane. Postrhinoscopic examination may 
show either cicatricial contraction, overlapping adenoids, or collapse of 
the Eustachian orifice. The pillars (glossopalatine and pharyngo- 
palatine arches) of the fauces may be adherent to the tonsils, and cause 
more or less atony of the palatal muscles. The diagnostic tube used 
during inflation gives the strident or rough murmur characteristic of 
tul)al olvstruction. 

Complete Obstruction. — This condition may be due to any one or 
more of the causes given imder Partial Obstruction, although it is usually 
due to syphilitic, tuberculous, or diphtheritic cicatricial contraction at 
the mouth of the tube. The symptoms are the same as in partial 
obstruction, excepting that tympanic inflation gives no rale or murmur 
through the diagnostic tube. 

Undue Patency of the Eustachian Tubes.— This condition is 
nearly always associated with atrophic changes in the entire mucosa of 
the upper respiratory tract, especially of the nose, epipharynx, and oro- 
pharynx. The process may not involve the entire Eustachian tube, 
but may be limited to the pharyngeal orifice. Urbantschitsch reports 
a case of this kind in which the end of the little finger could be inserted 
into the orifice. 

The characteristic symptoms are the inward and outward movements 
of the drumhead synchronous with the respiratory movements, the soft 
blowing murmur being heard through the diagnostic tube, even without 
inflation. There may be autophony or the ringing of the patient's 
voice in his own ears. The voices of others sometimes give rise to the 
same disagreeable sensation. The symptom is somewhat difi'erent from 
hyperesthesia acoustica, in which there is a painful distinctness of hearing; 
whereas in autophony the patient's own voice seems to ring or roar in 
his head. 

Treatment of Obstruction and Undue Patency. —The treat- 
ment of partial obstruction varies with tiie lesion causing it. If there 
is catarrhal congestion of the mucous membrane at the pharyngeal 
orifice relief may be afforded by the judicious use of antiseptic and astrin- 
gent sprays in the nose and epipharynx. If, however, the hyperemia 
is due to anterior nasal obstruction, this should be corrected. The re- 
moval of postnasal adenoids is indicated to relieve the epipharyngitis 
and the resulting tubal catarrh, as well as to overcome the mechanical 
obstruction thev mav form at the mouth of the tube. 



OBSTRUCTION OF THE EUSTACHIAN TUBE 657 

It is difficult to overcome cicatricial contraction, especially if it is due 
to syphilis. If due to diphtheria and tuberculosis, electrolysis may be 
of value. An olive-tipped electrode with the curvature of a Eustachian 
catheter, should be introduced through the nose after the manner of 
introducing a catheter. The tip should be made to enter the Eusta- 
chian orifice, the postrhinoscopic mirror being used to make sure of its 
position. The shaft of the electrode should be covered with some insu- 
lating substance. The strength of current should vary from 5 to 30 ma. 
according to the density and resistance of the tissue. Seances should 
last for from five to twenty minutes. The negative pole of the battery 
should be connected with the Eustachian electrode, as the tissue to be re- 
duced is dense and fibrous. If it is a simple hypertrophy, the positive pole 
should be used. If the lumen of the tube is constricted higher up by 
adhesive bands, a small, gold-tipped electrode should be introduced 
through the Eustachian catheter until it comes in contact with the con- 
striction, as recommended by A. B. Duel. A current of from 5 to 
25 ma. should be turned on for from five to fifteen minutes. It is 
claimed for electrolysis in these cases that the obstruction disappears 
and the hearing and tinnitus are improved. Others have found it of 
no practical value. The status of electrolysis at best is open to criticism. 
The benefits derived from it within the Eustachian tube may well be 
attributed to the dilatation and inflation which are incidental to the 
procedure. Theoretically electrolysis is an ideal treatment for fibrous 
constriction, while practically it has been disappointing. 

The use of bougies in reducing tubal stenosis has long been recognized 
as of considerable value in those cases in which the stricture is not com- 
posed of connective tissue. If it is due to turgescence or simple hyper- 
trophy, the results are often good. The bougies may be made of silk- 
worm-gut, whalebone, or celluloid. Those made of silkworm-gut may 
be impregnated with astringent remedies, as silver nitrate, sulphate of 
zinc, etc., which often adds to the therapeutic effect. The whalebone 
bougie is easier to introduce on account of its polished surface. Cellu- 
loid bougies are also smooth and easy to introduce, but are more liable 
to break. 

Suarez di Mendoza has devised a metal catheter which may be removed, 
leaving the bougie in the Eustachian tube. The catheter is divided 
longitudinally into two parts, and it can be separated and removed, 
leaving the bougie in position. It is then cut oft" even with the nose 
and left in position for twenty-four hours. By this method great dilata- 
tion is obtained. 

Caution. — The introduction of bougies into the Eustachian tube may 
injure the mucosa, hence emphysema of the submucous tissue may occur 
if inflation is practised immediately afterward. This procedure should, 
therefore, not be done immediately after passing tlie bougie into the 
tube. It should rather be done when the patient returns two days later 
for another treatment. The introduction of bougies may be practised 
two or throe times a week. In favorable cases the rough strident murmur 
hoard tiu-ough the diagnostic tube during inflation will have been replaced, 
after a few treatments, by a soft, full, blowing nuii-mur. 
42 



658 



THE EAR 



In some cases great difficulty is experienced in passing the bougie 
beyond the pharyngeal orifice, as it bends and returns to the pharynx 
with a sharj) tingling or smarting sensation in the lateral walls of the 
pharynx. The Eustachian catheter should be given a larger and 
sharper curve, so as to direct the tip of the bougie more in the direction 
of the lumen of the tube. 

The bougie should be made to persistently press against the con- 
striction until it passes it, or until the hope of doing so is abandoned. 
Larger bougies may be successively introduced until inflation gives a free, 
full, blowing murmur. After this they should be passed at longer in- 
tervals for several weeks or montlis. 




Weaver's intratympanic masseur. 



Massage of the Eustachian tube may be accomplished by the Weaver 
masseur (Fig. 363). The masseur is attached to the catheter and the 
current of air from the compressed-air tank turned on, the turbine wheel 
interrupting the current of air. The mucous membrane lining of the 
tube is thus rapidly and intermittently dilated. The bloodvessels and 
lymphatics are unloaded, and the glandular elements are stimulated 
to greater activity. The tympanic cavity is also inflated and the air 
tension restored. In turgescence and hyperemia of the tubal membrane 
this mode of treatment is highly commended. 

It should be said in conclusion that no one mode of treatment is appli- 
cable to all cases. Each should be carefully studied and all the facts 
considered before determining the line of treatment. The nasal and 
cpiphar)nigeal condition, as well as the general health, should be 
regarded as essential factors in determining the course of treatment in 
each individual case. 



CHAPTER XL. 

THE PRINCIPLES AND METHODS OF TYMPANIC INFLATION. 

The data of an anatomical, physiological, and clinical character, 
upon which the principles of tympanic inflation should rest is as 
follows : 

(a) The Eustachian tube extends from the lateral wall of the epi- 
pharynx to the cavity of the middle ear in an upward, outward, and back- 
ward direction. If the head is rotated to the right, and then inclined 
forward, the right Eustachian tube will stand perpendicular to the plane 
of the earth, thus favoring the drainage of the right middle ear. 

(6) The pharyngeal orifice of the Eustachian tube is trumpet-shaped, 
hence when a current of air is forcibly thrown into it the contained secre- 
tions are "dished" out and carried into the epipharynx, while the 
residual air passes on through the tube into the middle ear. 

(c) The walls of the Eustachian tube are covered with ciliated epi- 
thelium, the cilia creating a current toward the pharyngeal orifice. If 
the secretions are thick and become dried in the orifice, the sudden 
impact of air during inflation dislodges the mass and clears the way for 
the successful inflation of the middle ear. 

(d) The walls of the tubes are approximated when in the normal state 
of rest, and are only opened during inflation of physiological or artificial 
origin. 

(e) The drumhead, being the only yielding wall of the tympanic cavity, 
is pushed outward toward the external meatus during inflation. 

(J) The handle of the malleus is carried outward also, as it is in inti- 
mate relationship with the drumhead. 

(g) The incus and the stapes follow the outward movement of the 
malleus to only a limited extent, as the articulations are such as to per- 
mit the malleus to swing in this direction without marked movement of 
the other ossicles. The inward movement of the handle of the malleus 
is, however, accompanied by a corresponding, though more limited, 
movement of the incus and tlie stapes in the same direction. 

It is obvious, therefore, that in adhesive processes aft'ecting the mo- 
tion of the malleus inflation exerts more or less influence in breaking 
them down; whereas if the adhesions aft'ected the incus and the stapes, 
but slight influence is exerted. 

(h) Tlie mucosa of the tympanic cavity is supplied by numerous 
bloodvessels, capillaries, and lymph channels, which upon inflation (in 
catarrhal inflammation)j[become less engorged and return to their 
normal state of fulness."^ In other words, inflation is followedjiby 
an active hyperemia and an approach toward normal physiological 



660 THE EAR 

activity of the tissues composing the mucous membrane. The secre- 
tions become more normal and thinner in character. They are, there- 
fore, more easily carried toward the Eustachian tube by the wave-like 
motion of the ciliated epithelium. 

(0 The oxygen is gradually absorbed from the air within the tym- 
panic cavity, hence after several hours rarefaction takes place, thereby 
again giving rise to retraction of the drumhead. This does not occur in 
normal conditions, as air is admitted to the middle ear during each act 
of deglutition and yawning. 

ij) The palatal muscles have more or less control over the patency of 
the tubes, hence it is important that they be free to act to their full 
capacity. Repeated inflammation of the tonsils and fauces gives rise to 
adhesions to the pillars of the fauces (glosso-and pharyngopalatine arches) 
and to degenerative changes in the muscular tissue. The action of the 
palatal muscles is thereby interfered with and the regulation of the patency 
of the tubes is impaired. The ventilation of the tympanic cavity cannot 
be fully accomplished, hence more or less deafness and tinnitus follow. 

{k) Passive congestion of the mucosa also results from the rarefaction 
of the air in the middle ear, and leads to abnormal activity of the mucous 
glands, as well as to a change in the character of the secretion. A true 
catarrhal state is thus induced. Repeated inflations, together with 
other appropriate treatment of the nose and throat, will, in many cases, 
be followed by a lessened congestion, a restoration of the glandular 
activity, and a return to the physiological ventilation of the tympanum. 

(/) Thick, tenacious secretion is not easily forced from the middle ear 
through the Eustachian tube by inflation, "lie circulation and the 
glandular elements of the mucous membrane become impaired. Never- 
theless, the thick tenacious secretion is gradually absorbed or dis- 
charged. 

{m) The transmission of sound waves through the ossicular chain to 
the labyrinth is only perfectly performed when the tension existing be- 
tween the drumhead, the ossicles, and the intralabyrinthine fluid is nor- 
mal. If the tension is disturbed, more or less impairment in hearing 
results. Tympanic inflation restores the normal tension, unless adhe- 
sive bands prevent the drumhead springing into position. 

{n) When the drumhead is perforated, the secretion flows from the 
middle ear into the external auditory meatus. 

The foregoing data show that the objects of intra tympanic inflation 
are as follows : 

1. To restore the normal tension between the drumhead, the ossicles, 
and the labyrinth. 

2. To restore the normal circulation in the bloodvessels and the lymph 
spaces. 

3. To render the secretions more nearly normal. 

4. To remove the morbid secretion from the Eustachian tube and the 
tympanic cavity. 

5. I'o break down newly formed adhesions. 

By establishing the foregoing conditions tinnitus is relieved, hearing 



THE PRINCIPLES AND METHODS OF TYMPANIC INFLATION 661 

improved, catarrhal inflammation checked, and the suppurative pro- 
cesses amehorated. 

Methods of Inflation. — Valsalva's Method of Inflation. — While this 
method is not of such general utility as either Politzeration or catheteri- 
zation, nevertheless it has a place in otological practice which is not filled 
by either of the other methods. Although its therapeutic effects are 
rather limited, it is of diagnostic value. 

The method consists in compressing the air in the middle ear by a 
forcible expiratory effort while the mouth and the nose are closed. The 
method is successful in proportion to the dynamic power of the muscles 
of the individual and the character and degree of the obstruction in the 
Eustachian tube. The muscular power in children and women is less 
than in adult males, hence it is proportionately less successful in the 
former. 

The hindrances to the successful performance of inflation are: (a) 
Thick, tenacious secretions in the mouth and the lumen of the tube, as 
well as in (6) the tympanic cavity. Plugs of tenacious mucus some- 
times lodge in the tube and greatly interfere with the procedure. (c) 
When the tympanic cavity is in a state of partial vacuum from the 
absorption of the oxygen from the contained air, the tube is collapsed 
by the suction thus created. Inflation is thereby rendered difiicult, 
greater force being required for its performance, {d) Fibrous adhesive 
bands resulting from chronic inflammation of the tubal membrane 
may stretch across the lumen of the tube and obstruct it. (c) The 
mucous membrane in a state of catarrhal inflammation is congested or 
even hypertrophied, thus interfering with tympanic inflation, (j) The 
mucous membrane of the Eustachian tube is supplied with lymphoid 
tissue, which under favorable conditions undergoes an hypertrophy akin 
to the same process in adenoids and tonsils, thereby diminishing the 
lumen of the tube, {g) Thick, tenacious secretions in the middle-ear 
cavity also offer resistance to tympanic inflation, {h) The fact that there 
is no exit other than the Eustachian canal for the air entering the middle 
ear is another factor of some importance. It does not seem to the author, 
however, that it plays the major role assigned to it by some authors, 
notably Politzer, who thinks the drumhead offers considerable resistance, 
whereas it is only necessary to open the Eustachian tube, when the air 
will rush in from the epipharynx to equalize the pressure on the two 
sides of the drumhead. This is the result of physical laws, and requires 
no force or artificial intervention other than a patent Eustachian tube. 
After this is accomplished the air in the middle-ear cavity may be 
compressed even beyond the line of equilibrium, in order to stretch or 
break down adhesive bands, or to expel the secretions. 

The diagnostic value of this method is inferior to the others, inasmuch 
as it is less sure of being successful. Its successful performance in 
normal cases is attended by a soft blowing sound. Politzer ascribes 
the sound to the outward bulging movement of the drumhead. The 
author is inclined to take the view that it is due to the friction of the cur- 
rent of air in its passage through the collapsed Eustachian tube. If the 



GG2 THE EAR 

tube is filled with secretions, as in moist tubal catarrh, the sound is 
changed to a moist bubbling murmur. 

The prognostic value of the method is considerable, in view of the fact 
that in those cases of catarrhal otitis media in which it can be success- 
fully performed the prospects of cure or relief are good. 

Caution. — A word of caution should be given in regard to the evils 
attending its use as a therapeutic measure. When the hearing, the tin- 
nitus, and the "stuffed-up" feeling in the ears are relieved by this method, 
the patient is tempted to resort to its use so frequently and for so long a 
period of time that there is great danger of overstretching the membrana 
tympani, thereby rendering it atrophic. The author never recom- 
mentls the method for therapeutic purposes, but, on the contrary, often 
discourages its use by those who have already adopted it. 

The method, therefore, is of value chiefly as a diagnostic and prog- 
nostic procedure. 

Catheterization. — This method was first brought to the attention of the 
Paris Academy in 1724 by a postmaster named Guyot, but its therapeutic 
value was not clearly stated until a century later by Saissy, in his treatise 
on the Diseases of the Internal Ear, 1819. 



-W 



Bulbous-tipped silver Eustachian tube. 



The Binnafont or Kramer Method consists in introducing the catheter 
(Fig. 364) through the inferior meatus of the nose into the epipharynx, 
where it is turned outward and upward into the mouth of the 
Eustachian tube. The curved tip of the catheter should be kept on 
the floor of the nose at the junction of the floor and the septum. 
When the tip touches the posterior wall of the pharynx it should be 
rotated outward into Rosenmiiller's fossa, then rather quickly drawn 
forward over the bulging posterior lip (plica salpingopharyngeus) of 
the Eustachian orifice into the pharyngeal mouth of the tube. The 
eyelet of the catheter indicates the direction of the curved tip, which, 
when in the mouth of the tube, is generally turned in an upward and 
outward direction, toward the outer can thus of the eye. In some 
cases, however, the tip enters the orifice when directed horizontally 
outward. 

It may be necessary to change the angle of the curvature of the tip to 
suit individual cases. Saissy recommends an angle of 130 degrees, 
while Politzer advises 145 degrees. 

The best instruments are made of pure silver, as they can be easily 
changed in shape and may be sterilized in boiling water. This is of no 
little importance when the liability to infection is taken into considera- 
tion. Before the days of sterile surgery hard-rubber catheters were 
largely used, and they are still recommended by some authors. Saissy, 



THE PRINCIPLES AND METHODS OF TYMPANIC INFLATION 663 

however, nearly one hundred years ago, recommended silver, which is 
today preeminently the best material for the purpose. 

The Lowenberg Method. — The Lowenberg method consists in turning 
the tip of the catheter, after it has entered the epipharynx, toward the 
median line, until the metal ring on the outer extremity assumes the 
horizontal position and then drawing it forward until it touches the pos- 
terior extremity of the septum. In making the forward movement the 
outer extremity should be slightly removed from the septum, so as to 
bring the curved tip beyond the median line, thereby making sure that it 
catches on the septum. The outer end of the catheter should then be 
moved toward the nasal septum, and held near the tip with the fingers 
of the left hand. It should then be rotated downward and outward 
more than 180 degrees, or through more than half a circle, into the 
pharyngeal orifice of the Eustachian tube. If there are no malforma- 
tions and the velum palati is not so tense as to displace the tip backward, 
it will enter the orifice, where it should be held during inflation. 

Fig. 365 




Inflation of the cavum tympani with the Eustachian catheter and compressed air. The diagnostic 
tube extends from the ear of the surgeon to the ear of the patient. (American method.) 



The fixation of the catheter, after it has been properly introduced into 
the pharyngeal orifice of the Eustachian tube, is most easily accom- 
plished by grasping the free end between the thumb and the forefinger, 
while the other fingers rest across the bridge of the nose. 

The Auscultation or Diagnostic Tube (Fig. 365) should be used to deter- 
mine wlu^thcr tlie catlieter is in place. The statements of the patient on 
this j)oint are not trustworthy, as the sensation produced by inflation 
often gives ri.se to a feeling of fulness in the ears wlien the auscultation 
tube does not confirm the patient's statement. Tlie physician should 
make a common practice of using the auscultation tube when inflating 
tiic ears, not alone to judge whether the procedure is successful, but to 
enable him to determine the condition of the Eustachian tube and the 
middle ear. If there is a .soft blowing murmur the tube is normally o])en , 
although it may be normally inflated and the inurTuur not heard. This 
is exceptional, however, and the fact of inflation can be demonstrated 



6fi4 THE EAR 

by using the manometer tightly fitted into the external auditory meatus. 
The U-shaped tube of the manometer should contain a few drops of 
colored fluid, which will be seen to rise in the outer arm of the mano- 
jnetric tube when inflation is accomplished. If the Eustachian tube 
is obstructed by catarrhal swelling or hypertrophy of the mucous mem- 
brane, the character of the sound during inflation becomes sibilant 
and rough. The presence of mucus in the tube is indicated by moist 
bubbling rales. It occasionally happens that at the beginning of infla- 
tion there are signs of obstruction, which after a few moments suddenly 
disajjpear. In these cases it is probable that a thick plug of mucus at 
first obstructs the tube, which soon becomes dislodged. In atrophic 
otitis media the Eustachian tube is correspondingly open and of a soft 
blowing character. 

Other Methods of Catheterization. — There are several other methods of 
catheterizing the Eustachian tubes not commonly used, that in excep- 
tional cases may be resorted to. 

(a) Catheterization from the opposite nasal cavity may be done with 
the ordinary catheter in those cases in which there is a narrow pharyngeal 
vault by introducing it along the floor of the nose in the usual way until 
it reaches the posterior wall of the pharynx, then rotating the curved tip 
toward the opposite Eustachian orifice until the ring on the outer end of 
the catheter stands horizontally, or points toward the median line. The 
outer end of the catheter should now be removed from the septum, thus 
bringing the tip in approximation with the pharyngeal opening of the 
tube. Gentle pressure in a backward direction will bring it well into the 
opening. Inflation can now be practised in the usual manner. 

This method may be used when there are obstructive lesions in the 
nose upon the side to be catheterized and in those cases in which there is 
congenital occlusion of the posterior nares on that side. 

(6) Catheterization through the mouth may be done by using an instru- 
ment with a longer curve than is ordinarily used through the nose, the 
postrhinoscopic mirror aiding in placing the tip in the mouth of the tube. 
When there is cleavage of the palate it may be done with the ordinary 
catheter, as the soft palate is out of the way, thereby enabling the oper- 
ator to reach the mouth of the tube with the shorter curved tip. It can 
also be done in many cases without the use of the postrhinoscopic 
mirror, as the pharyngeal openings may be seen with the unaided eye. 

The Diagnostic and Therapeutic Value of Catheterization. — There are 
various methods of forcing air through .the catheter into the middle ear, 
all of which are of value, the choice of method depending largely upon the 
mechanism afforded by the local instrument dealers rather than upon 
the peculiar merits of any individual method, (a) The Politzer bag, 
as shown in Fig. 366, is connected directly with the Eustachian catheter, 
and is, perhaps, the most familiar apparatus for this purpose, owing to 
the distinguished reputation of its inventor. It is admirably adapted 
to the use of general practitioners on account of its simplicity and the 
slight expense of the appliance. 

ih) The equipment of a modern American otologist, however, usually 



THE PRINCIPLES AND METHODS OF TYMPANIC INFLATION 665 

affords appliances which are even more convenient, and perhaps more 
scientific in their appHcation in oiSce practice than the Pohtzer bag. 
Many offices in the large cities now have compressed air piped through 
the building, and with a gauge the desired pressure can be established 
for each individual case. The shut-off should be applied to the ex- 
panded end of the catheter after it is properly adjusted, and inflation 
accomplished by liberating the air by means of the lever, as is done in 
spraying the nose or throat. The exact amount of air pressure can be 
accurately estimated by the pressure gauge. The author uses the regu- 
lator attached to the compressed-air tank devised by Edwin Pynchon. 
It is so arranged that the amount of air pressure can be quickly adjusted 
to the needs of the case. The author has found that a pressure of from 
seven to twenty-five pounds is all that is ordinarily required for the infla- 
tion of the middle ear. In some cases a pressure as low as five pounds 
is quite adequate for the purpose. It appears, therefore, that in offices 
equipped with compressed air, which is piped all over the building and 
can be tapped as is illuminating gas, an arrangement of this kind is 
admirably adapted to the purposes of the otologist, and renders the 
work of inflation more exact and scientific in its application. 

(c) The nebulizing inflator is an mstrument whereby inflation can be 
performed through the catheter in a very simple and easy manner. The 
tip of the nebulizer is made to fit into the expanded end of the catheter, 
and the medicated nebula is driven through the catheter into the middle 
ear. The impact of the medicated air thus released passes through 
the tube and the catheter to the middle ear. This appliance affords 
a convenient and simple means of applying medicated vapors to the 
middle ear. 

The diagnostic tube should be used in connection with this method, 
and the character of the sounds transmitted through it noted for diagnos- 
tic and prognostic purposes. 

(d) The Victor electric pneumomassage apparatus shown in Fig. 15 
may also be used to infiate the middle ear through the Eustachian cath- 
eter by attaching the rubber air hose to the expanded end of the catheter 
and setting the pump in motion as for massage through the external 
meatus. The pump may be adjusted so as to produce continuous com- 
pression of the air. The pressure is discontinued by elevating the lever, 
which raises the contact wheel, thus instantly stopping the action of the 
pump. After a few moments the lever may be lowered, bringing the 
wheel into contact with the one attached to the revolving armature of 
the machine, thereby starting the air pressure again. This may be 
repeated as often as is necessary according to the judgment of the 
operator. 

Politzer's Method. — In 1863, Politzer^ introduced a method of inflating 
the middle-ear cavities which still proves of the greatest utility in aural 
practice. It is performed with a pyrifonn rubl)er bag (Fig. 360), of 
about ton ounces' capacity, to which is attached a nozzle suitable for 

I Wiener nied. Woclieiisuhiift, Nr. 0. 



G66 



THE EAR 



introduction into the anterior nares. The patient is seated in front of the 
operator, tlie nozzle inserted well into one nostril, while the opposite 
nostril is firmly closed. The index and the middle fingers of the oper- 
ator's left hand should engage the tip of the nose, while the thumb com- 
pletes the closure of the nostrils. The patient is then instructed to 
swallow, and as the laryngeal box is observed to rise the bag is forcibly 
compressed with the operator's right hand. The nozzle and the opera- 
tor's fingers completely close the anterior nares, while the act of swallow- 
ing brings the muscles of the soft palate and of the posterior wall of the 
pharynx into apposition, thus completely walling off the respiratory path 
in that direction. The compressed air thus confined finds the point of 
least resistance via the Eustachian tubes. The impact of air is conveyed 
to the middle ear and inflation accomplished. The method is simple, 




Politzer's bag and ti 



the instruments of simple construction and slight expense, and the pro- 
cedure is easily performed. The act of swallowing, if performed more 
than once or tw^ice, becomes quite difficult for the patient unless aided 
by the use of a sip of water. 

Miot introduced a simple expedient which in some respects is more 
convenient than water. Sugar lozenges are kept on the treatment table, 
and one given to the patient before performing inflation. As the lozenge 
is dissolved in the mouth of the patient the act of swallowing is easily and 
naturally performed as often as necessary without the inconvenience 
attending the use of water. 

The author, in using the Politzer bag, places a piece of soft-rubber 
tubing, one foot long, between the tip of the bag and the nozzle (Fig. 367). 
By this measure the liability of mechanical injury to the mucous mem- 
brane of the nose in the act of forcibly compressing of the bag is avoided. 



THE PRINCIPLES AND METHODS OF TYMPANIC INFLATION 667 

The bag in the hand of the operator has great freedom of movement 
about a circle the radius of which is approximately twenty-four inches. 

Auscultation during the use of the Politzer method shows two sets of 
sounds, one due to the entrance of air into the middle-ear cavity, the 
other to the escape of air in the epipharynx. The former is a soft 
blowing murmur when the drumhead is intact, while the latter is rough, 
loud, and gurgling in character. After a little experience the tympanic 
sounds may be readily distinguished from the rough pharyngeal noises; 
indeed, the latter are soon disregarded altogether. If for any reason 
the tympanic murmur is not heard, the use of the manometric tube 
should be resorted to in order to determine whether the air is forced into 
the middle ear. 

Inspection of the drumhead during inflation may not show any 
appreciable movement of the same. Here, again, the manometric tube 
may be used to more accurately demonstrate the actual amount of infla- 
tion. 

It sometimes happens that inflation cannot be performed by Politzer's 
method, in which event the use of the catheter is usually indicated. 

Fig. 367 




Politzer's bag and tube for use with a Eustachian catheter or nasal tip 



A Modified Politzer Method. — The American Method. — The author 
uses a modification of Politzer's method whereby the rubber bag is 
discarded and the compressed-air apparatus is substituted therefor. It 
is not only a more convenient, but also a more sure method of inflation. 
A suitable nose-piece adapted to receive the tip of the shut-off of the air 
tank tube, such as is used with spray bottles, comprises the outfit. 
Pynchon has modified Buttles' inhaler in such a way as to un- 
screw the acorn-shaped nose-piece at about its middle portion (Fig. 
302), thus affording an easy means of introducing pieces of sponge, 
gauze, felt, or cotton-wool upon which volatile medicaments may be 
dropped and l)lown into the tympanic cavity. The Buttles-Pynclion 
inlialer is so constructed as to be used with the ordinary shut-oft' of a 
comj^ressed-air apparatus, and for office use should take the place of the 
Politzer bag, as it is more convenient to use, is indestructible, and is a 
ready means of conveying medicated vapors to the tympanic cavity. 
By means of the compressed-air tank with a pressure regulator tlie 
exact amount of air pressure needed to inflate the ear may be estab- 



668 THE EAR 

lished for each at the time of the primary examination. This should be 
made a part of the record, and iitihzed in the future treatments. If it 
is found after a few treatments that inflation is accomphshed with less 
air pressure than was at first required, a favorable prognosis may be 
given. This method appears to be founded upon a more accurate basis 
than Politzer's, in which the amount of pressure used cannot be accu- 
rately estimated or regulated. There are few offices that are not pro- 
vided with a compressed-air apparatus; hence, the Politzer bag might 
well be superseded by a simple nose-piece and the compressed-air tank 
and gauge regulator in office practice. For bedside practice and for 
home use the Politzer bag still holds a distinct and useful place in 
otological practice. 

External Mechanical Massage. — In the hands of the author external 
mechanical vibration below the angle of the inferior maxilla has proved a 
valuable adjunct to the inflation of the middle ear. In some cases which 
resisted successful inflation mechanical massage applied in this region 
with the vibrator was followed by successful inflation. The mechanical 
vibration thus imparted probably lessened the passive congestion of the 
mucosa of the pharynx, tonsils, and faucial pillars, and thus favorably 
influenced the mouth and the lumen of the Eustachian tube. 

Comparative Value of the Methods. — It may be said that no one method 
should be used to the exclusion of all others. Each will, under certain 
circumstances, answer the purpose better than another. The condi- 
tions favorable to the employment of any method cannot always be 
foreseen, but can only be ascertained by trial. The author has often 
found it impossible to inflate by catheterization when he could do 
it readily by the Politzer method, or vice versa. He has also found the 
Politzer method inadequate in some instances in which the modification 
described by the author, using the compressed-air tank and a nose-piece, 
did the work satisfactorily. 

Valsalva's method is commended on account of its simplicity and the 
absence of instruments of any kind in its performance. On the other 
hand, it is to be strongly condemned on account of the ease with which 
it may be abused. It is done entirely by the patient, and the relief it 
affords may tempt him to resort to its use much oftener than is neces- 
sary or safe. There are few cases requiring inflation oftener than once 
on each alternate day for a period of six weeks. With Valsalva's 
method the patient often inflates his ears several times daily for many 
weeks or months, thus producing pressure atrophy of the drumhead. 
When this condition arises the state of the patient's ears is worse than 
before treatments were given. 

Catheterization is regarded by many as the most effectual method of 
inflation yet devised. In the author's experience, a louder tjaiipanic 
murmur is heard by this than by any other method. He believes, there- 
fore, that where it can be used without great discomfort to the patient it 
should be given preference. However, there are certain nasal deformi- 
ties which may prevent, or at least greatly hinder, its successful use. 
Some other method, preferably the tank and nose-piece, should then be 



THE PRINCIPLES AND METHODS OF TYMPANIC INFLATION 669 

used. Politzer himself claims more for his method than for any other, 
not excepting catheterization. 

The Politzer method is extensively recommended and used on account 
of its simplicity and the ease with which it is practised. In those cases 
in which the catheter cannot be used, as in marked nasal obstruction, 
hypersensitiveness of the mucosa, timid patients, and children, it should 
be elected as preferable to catheterization. 

Unless the diagnostic (auscultation) tube is used, the operator is 
never certain of the results obtained by any method whatsoever, the 
patient's statements often being untrustworthy. 

The modified Politzer method, in which the compressed-air tank takes 
the place of the rubber bulb, is ordinarily preferable to the Politzer 
method, as it can be accurately regulated ito suit each case, and has a 
wider range of atmospheric pressure. The tympanic murmur is louder 
and is heard much longer and more continuously on account of the con- 
stant air pressure than with the short puff obtainable with the Politzer 
bag. The author believes, however, that where catheterization can be 
done with little discomfort to the patient it should be given preference. 

Recapitulation. — 1. Catheterization is the most effectual method of 
inflation in most subjects. 

2. The compressed-air tank and nose-piece are preferable if, for any 
reason, catheterization cannot be performed. 

3. The Politzer method should be used in bedside practice and as a 
"home treatment," and in all other instances in which the compressed- 
air apparatus and nasal tip are not available. 

4. Valsalva's method should only be recommended when the others 
are not available, and then only with strict instructions as to its possible 
evil results if the directions as to the frequency and period of use are 
strictly followed. 



CHAPTER XLI. 

INFLAMISIATORY DISEASES OF THE TYMPANUM. 
ACUTE CATARRHAL OTITIS MEDIA. 

Acute catarrhal otitis media comprises about 13 percent. (Hovell) of 
all ear diseases; it is, therefore, a very important division of otology, and 
should be considered in some detail, especially in view of the fact that 
the general practitioner is so frequently called upon to treat it. 

General Etiology. — The causes of simple catarrhal otitis media are 
numerous, and may be considered under three different headings, 
namely: 

1. Exciting causes, or pathogenic microorganisms. 

2. External influences, or those conditions external to the body which 
act as predisposing causes. 

3. Internal influences, or those conditions within the body which pre- 
dispose to otitic inflammations. 

1 . Exciting Causes .—The exact relation of microorganisms to the inflam- 
mation of the middle ear is not yet fidly determined. That they are 
found in healthy ears is probable, as the investigations by Zaufal have 
shown them to be present in the ears and epipharynx of rabbits. We 
know that the various infectious fevers, as scarlet fever, measles, diph- 
theria, etc., are often accompanied by acute catarrhal otitis media, 
although complications from these sources are very prone to take on the 
suppurative type. There is no special bacteria which causes catarrhal 
inflammation of the middle ear, but there is usually a combination of two 
or more, such as the Diplococcus pneumoniae and the Streptococcus 
pyogenes. The Staphylococcus pyogenes albus and aureus, and the 
Bacillus pyocyaneus are next most frequently found in the middle ear. 
Friedlander's bacillus is less frequently found in combination with the 
Staphylococcus cereus albus. Bacillus pyocyaneus, and the Micrococcus 
tetragenus. These and other microorganisms may be present in the 
tympanic cavity without exciting inflammation. It is necessary that the 
conditions of the secretions and the tissues be favorable for their rapid 
]:)ropagation before they are able to excite an inflammatory process. It 
has been found that the invasion of a new micro5rganism is sufficient, 
under certain circumstances, to excite inflammation. After the inflam- 
mation has subsided the invasion of another type of microorganism may 
cause a recurrence of the inflammation. The question of microorgan- 
isms in their relation to inflammatory processes is still involved in so 
much speculation and doubt that it is impossible to give any definite 
statement as to the exact influence they have as etiological agents in 



ACUTE CATARRHAL OTITIS MEDIA 671 

catarrhal inflammations. It seems that after the primary irritation of 
the tissues has subsided, the soil is prepared for other germs, so that 
upon their entrance there is a recrudescence of the inflammatory process. . 

It is well known that pathogenic microorganisms are more virulent 
at times than at others, hence the presence of microorganisms per se is 
not sufiicient to cause acute inflammation. They must be of the proper 
virulency, the soil must be prepared to favor their activity, and the cellu- 
lar structures must be so modified in their functional activity as to be 
unable to resist their influence. Even the tuberculous bacillus may be 
found in the secretions of the middle ear without giving rise to pathological 
changes . 

Channels of hivasion. — Microorganisms nearly always gain access to 
the tympanum through the Eustachian tube. There are several other 
routes, however, through which they may enter it. The bloodvessels 
may carry them to the mucous membrane of the tympanum, where they 
may be thrown out with the serum and mucus, and thus give rise to 
inflammation. They may also gain access through the drumhead, 
when it is perforated, either from congenital or pathological states. In 
rare instances they may gain entrance from the cranial cavity through 
the bony walls, or through the internal auditory canal and labyrinth. 

As has been stated, they most frequently gain entrance through the 
Eustachian tube. This may occur in spite of the fact that the tube is 
lined with ciliate columnar epithelium, whose ciliae create a current toward 
the epipharynx. The Eustachian tube is patent as it momentarily 
opens to admit air into the tympanum, and the microbes may be swept 
inward with the current of air to the middle ear. During paroxysms of 
sneezing or vomiting the microbes may also be carried from the epi- 
pharynx into the tympanum. Hence there is no absolute physio- 
logical barrier offered by the ciliated epithelium of the tube to the 
entrance of microorganisms into the middle ear. 

The microorganisms excite catarrhal inflammation which may assume 
the suppurative type. They may also be present without exciting any 
pathological reaction. 

2. External Influences. — The external causes of otitis media cannot 
be considered without also taking into account the internal conditions 
which predispose to it. It is convenient, however, for purposes of study 
to consider the external causes separately, and in so doing we shall have 
to take into consideration the local conditions of the upper respiratory 
tract, as well as certain constitutional states which will be considered 
in detail under the second type of general causes. 

Exposure to the weather is a fruitful predisposing cause of otitis media, 
especially when the tone of the system is not up to the normal standard. 
It the patient has chronic rhinitis or obstructive disease of the nasal 
cavities, or has adenoids and epipharyngeal inflammation, exposure 
to the inclemencies of the weather is especially liable to result in acute 
catarrhal inflannnalion of the middle ear. Certain other factors enter 
into this projiosition, as clothing, climate, zone, age, sex, and the occu- 
pation of the })atient. 



G72 THE EAR 

It seems appropriate, therefore, that these etiological factors should be 
considered under this heading, rather than under separate paragraphs. 
It is evident that the effect of exposure to the weather will depend very 
largely upon the amount and kind of clothing worn, and the climate and 
latitude in which the patient lives, as well as upon his occupation. Age 
and sex will, also, largely determine the amount of exposure to which the 
individual is subjected. The character and amount of clothing worn does 
not i')er se determine the influence that exposure to the weather will have 
upon the patient, as the habits of the individual and the character of the 
house in which he lives modify his susceptibility to such exposure. If 
lie lives in a house that is but partially heated, and has been accustomed to 
sleeping in a bed-room which was never heated, the exposure to the in- 
clemencies of the weather will not affect him as much as it will one who 
lives in a well-built house which is uniformly heated. 

jNIany of our country homes are so loosely constructed that they are 
well ventilated through the crevices about the windows and doors. There 
is not, therefore, the extreme difference between the condition indoors 
and outdoors as is found in the better portions of large cities. 

Those living in country houses are, therefore, subjected to a more 
even temperature and atmosphere, within and without the house, than 
those who live in closely built and better heated houses. They are, there- 
fore, not so susceptible to changes of weather, and the amount of clothing 
they wear, when exposed, need not differ so much in cjuantity and char- 
acter from that worn while indoors. On the other hand, those living in 
the city need to give more attention to the variations of their clothing for 
indoor and outdoor wear. 

I have known patients who were accustomed to country life, who were 
exposed to the inclemencies of the weather a hundred times more than 
they were in after years when living in the city, who were entirely free 
from catarrhal conditions of the nose and ears while living in the country, 
and who rapidly developed them after removing to the city. 

The catarrhal inflammation developed, in spite of the fact that they 
were taking extraordinary precautions, in the way of additional clothing, 
to protect themselves while outdoors. It seems, therefore, that the 
habits of life which tend to lower the cellular vitality have more to do 
with the predisposition of the upper respiratory tract to catarrhal inflam- 
mations than the amount or character of clothing worn. Our modern 
dwellings, with their superb heating plants, storm windows, etc., are, 
perhaps, less of a boon to humanity than is generally supposed. The 
more primitive style of living seems to accustom the system to the vari- 
ations in the temperature and hygroscopic conditions of the atmosphere. 
It is not reasonable, however, to expect that we will return to that mode 
of living. ^Ye can only say in this connection that in the construction 
of our houses more attention should be given to the question of ventila- 
tion. It has been said that good ventilation and cheap heating do not 
go hand in hand. Within certain limits this is undoubtedly true. Never- 
theless, the architect can do much toward the proper ventilation of 
dwelling houses without materially increasing the expense of heating. 



ACUTE CATARRHAL OTITIS MEDIA 673 

The attention of the piibhc should be frequently called to tliis fact 
until they are educated up to the point that they will demand that this 
problem receive appropriate attention at the hands of the architect. 

The climate and latitude in which one lives influence, in a marked 
degree, the character and amount of exposure to which one is sub- 
jected. In the temperate zone the climate is usually variable and subject 
to very rapid changes in temperature and hygroscopic conditions of the 
atmosphere, and is, therefore, one of the factors in the etiology of acute 
inflammations of the upper respiratory tract and middle ear. Those living 
in the more frigid and torrid zones are less exposed to sudden changes in 
the temperature and atmosphere, and are, consequently, less subject to 
catarrhal inflammations. Those living near large bodies of water, as the 
ocean, or the chain of Great Lakes between Canada and the United States, 
are especially affected by climatic conditions, as the atmosphere is moist 
and penetrating. The skin is thereby chilled and the vasomotor nervous 
centres are disturbed, and many of the functions of nutrition and metab- 
olism are modified in such a way as to excite inflammatory processes in 
the mucous membranes, especially those of the respiratory tract. 

Certain occupations give rise to greater exposure than others, conse- 
quently sex, which largely determines the nature of one's occupation, 
must have some influence in the etiology of this disease. A greater 
proportion of males are exposed to the inclemencies of the weather, hence 
catarrhal inflammation of the mucosa is more common with them than 
with females. 

Age also determines, to some extent, the amount of exposure. Young 
male adults in the vigor of life, full of ambition and enterprise, more 
often subject themselves to the inclemencies of the weather in the 
pursuit of their vocations than those who are younger or older. 
Hence we find catarrhal infiammation of the middle ear and upper 
respiratory tract more common in young adulthood than at any other 
period of life. 

A careful study of the above facts will demonstrate that exposure to the 
weather is a question of considerable complexity, as the effects of the 
exposure are largely determined by the mode of life, clothing, zone, age, 
sex, and occupation of the patient. It is not sufficient, therefore, for one 
to say to the patient, "You should not expose yourself to the inclemencies 
of the weather." All the facts pertaining to his mode of life should be 
taken into consideration, and advice given accordingly. It has become 
cjuite the fashion nowadays to tell patients that they sliould take a cold 
plunge bath each morning, and that they should walk at least five miles 
a day. This advice witii certain limitations is sound, and is based upon the 
data given above. The attempt is made by this procedure to bring the 
patient for a brief time each day back to the primitive methods of living. 
It is well known that life in the ojjeii air and sunshine, and a certain 
amount of exposure of the body to varying degrees of heat and cold, are 
favorable to the well-being of the system. 

More attention shoukl be given to this subject than is now done. 
The influence of sunshine upon the cellular vitality is greater, perhaps, 
43 



674 THE EAR 

than is generally appreciated. We know that many women work indoors 
all day, are constantly making physical exertion, and who are anemic and 
poorly nourished in spite of the fact that they have plenty of wholesome 
food. The same amount of exercise taken in the sunshine would trans- 
form them into robust, red-blooded women. It appears, therefore, that 
sunshine is one of the most potent therapeutic agents for the upbuilding 
of the system. I wish, therefore, in this connection to emphasize the im- 
portance of outdoor exercise. 

3. Internal Influences. — The internal conditions which predispose to 
catarrhal inflammation of the middle ear and upper respiratory tract 
have a more intimate clinical relationship to acute catarrhal otitis media 
than the external influences. It is well established that middle-ear dis- 
ease is almost invariably preceded by some form of nasal or epipharyn- 
geal disease. AVhatever causes the preexisting infection and inflamma- 
tion of the nasal mucous membrane or the mucosa of the epipharynx 
will also directly or indirectly lead to a similar condition within the 
Eustachian tube and middle ear. This is easily accounted for when we 
remember that the mucous membrane of the Eustachian tube and 
middle ear is a continuation or reflection of that lining the nose and 
epipharynx. It is quite similar in physiology and structure, and inflam- 
mations therefore readily extend from one part of it to another. If there 
is a difference in the structure of the mucous membrane, as in the 
mesopharynx, where the epithelium is squamous, the inflammatory 
process does not readily extend to the part. The mucosa of the nose, 
epipharynx. Eustachian tube, and middle ear are lined by columnar 
ciliated epithelium, hence there is no bar to the extension of the inflam- 
matory process from one to the other. 

I shall in this connection briefly refer to the diseases of the nose, 
epipharynx, and fauces which cause inflammatory diseases of the 
Eustachian tube and middle ear: 

(a) Nasal diseases which cause pathological processes within the middle 
ear are either inflammatory or obstructive in character. The inflamma- 
tory diseases are acute rhinitis, acute fibrinous rhinitis, diphtheritic 
rhinitis, syphilitic rhinitis, tuberculous rhinitis and catarrhal and suppura- 
tive sinuitis. The inflammation may extend to the middle ear through the 
Eustachian tube by continuity of tissue, or the pathogenic bacteria may 
invade the ear through the Eustachian tube or through the blood and 
lymph channels. They also influence the inflammatory changes in the 
middle ear by causing the closure of the Eustachian tube, thereby inter- 
fering with the ventilation of the tympanum. The oxygen is gradually 
absorbed from the middle ear, thus gradually rarefying the air. The 
blood within the vessels of the mucosa of the middle ear rushes in 
to All the partial vacuum thus created, and congestion and engorge- 
ment of the mucous membrane follow. This leads to changed nutrition 
of the parts and to a disturbed relationship of the cellular structures, 
which after a time predisposes to an inflammatory process. 
^ Nasal obstruction is also a fruitful source of ear disease. The pres- 
ence of spurs, ridges, thickening, and deflections of the septum cause 



ACUTE CATARRHAL OTITIS MEDIA 675 

stenosis of one or both nares. As the nasal cavities are the natural chan- 
nels for the inspiratory and expiratory currents of air, any interference 
with their patency results in physiological disturbances of a very pro- 
nounced character. When the diaphragm contracts, the thoracic cavity 
is enlarged and the air from without rushes in to fill it. If the nasal 
chambers through which the air enters the respiratory tract are ob- 
structed, the contraction of the diaphragm acts as the valve in a syringe 
when it is forcibly pulled out; the air is thus rarified posterior to the 
point of obstruction. The partial vacum thus created induces the rush 
of the blood to the vessels of the mucosa. This condition after a time 
leads to tissue changes and predisposes to inflammatory processes. The 
patency of the Eustachian tubes is thereby diminished, which still further 
impairs the middle ear. Hence nasal obstruction is a constant menace 
to the middle-ear cavity. 

All cases should be carefully examined for any diseased state of the 
nose, as the subsequent treatment of the case will depend very largely 
upon the successful treatment of these conditions. 

Ethmoiditis and sphenoiditis are a fruitful source of middle-ear inflam- 
mation. The morbid secretions from these cells flows into the epipharynx 
and excites an inflammation which in time extends by continuity of 
tissue to the Eustachian tube and middle ear. 

(b) Epipharyngeal diseases predisposing to middle-ear catarrh may 
be studied under two headings, namely, postnasal adenoids, or neo- 
plasms and epipharyngitis. The presence of postnasal adenoids in 
the vault of the pharynx gives rise to epipharyngitis, either of the 
catarrhal or suppurative type. For reasons already given, this inflam- 
matory process may give rise to middle-ear inflammation. Postnasal 
adenoids may be so situated as to close the mouths of the Eustachian 
tubes, which, as has already been explained, is a common cause of middle- 
ear catarrh. 

(c) Enlarged or diseased Jaucial tonsils have for many years been 
recognized as one of the principle etiological factors in the production of 
middle-ear disease. This relationship is readily understood when we 
remember that the tonsils are situated between the anterior and posterior 
piflars of the fauces (glosso- and pharyngopalatine arches). The pos- 
terior pillar embraces the palatopharyngeus muscle, which has some 
influence in controlling the patency of the Eustachian tube. It is appar- 
ent that when the tonsils are diseased the pillars are congested or 
inflamed, and in time their muscular fibers undergo more or less degen- 
eration and atrophy. 

{d) Tubal disease, while intimately associated with middle-ear disease 
in nearly every case coming under observation, may be present without 
giving rise to any evidence of middle-ear complications. In other words, 
there is a time when the inflammation extends from tlie epipharynx 
into the Eustachian tube, and does not yet involve the middle ear. I 
have already referred to the fact that congestion or obstruction of the 
Eustachian tube is a fruitful source of inflammatory diseases in the 
middle ear. I need not dwell upon it at greater length in this place. 



676 THE EAR 

(e) Constitutional disorders, as anemia, scrofula, syphilitic and tuber- 
culous affections, lower the vitality of the cellular structures, and thus pre- 
dispose the middle ear to inflammatory attacks. This has already been 
referred to under the external causes of otitis media. 

After all that has been said as to the causes of otitis media, we may go 
back to the primary statement that those influences external to the body 
which, under varying circumstances, affect the vasomotor system, and 
certain diseased states of the epipharynx, cause obstruction of the Eus- 
tachian tube and subsequent infection and inflammation of the middle 
ear. 

Pathology. — -The cavum tympani contains serum admixed with mucus 
in varying proportions. Epithelial cells are also found in the secretion. 
They show evidence of having undergone degenerative changes peculiar to 
inflammatory processes. While the secretion cannot be said to be sup- 
purative in character, it may contain a number of pus corpuscles. The 
mucous membrane of the middle ear, unlike that of the nose, has very 
few glands; hence, the mucus is formed from the chalice or goblet cells 
of the mucosa. In the nose the mucous is chiefly formed by the cells 
lining the glands, only a few goblet cells participating in its production. 
There is, therefore, in the middle ear a very rapid degenerative process 
(mucoid degeneration) going on during the acute inflammatory process. 
The intercellular spaces are filled with fluid, while the bloodvessels are 
very much congested, thus rendering the membrane very much swollen 
and thickened. The surface of the mucous membrane is denuded of 
epithelium in patches. Hovell calls attention to the fact that leukocytes 
are found mingled with the secretion in the immediate region of these 
patches. 

Pronounced destructive processes are not commonly present in this 
type of middle-ear disease. In rare instances, the drumhead is perforated, 
while there is more or less maceration of the mucous membrane lining 
the tympanic cavity. After a few days the morbid changes described 
above rapidly disappear, the mucous membrane returning to its normal 
condition. There seems, however, to be a peculiar susceptibility to recur- 
rent inflammations. This may be due to the fact that microorganisms 
of the proper virulency gain entrance to the cavity and, finding the soil 
prepared by the primary inflammatory process, readily excite a recur- 
rence of the same. 

General Symptoms and Diagnosis. — 1. Acute otitis media is usually 
due to a bacterial infection via the Eustachian tubes, though it occa- 
sionally enters via the blood current. The exudate may be simple or 
purulent. In simple catarrhal inflammation the drumhead rarely rup- 
tures, no matter how intense the inflammation may be. If the exudate 
is purulent there is a tendency to rupture at the point of greatest bulging. 
Severe simple catarrhal cases begin with the same constitutional dis- 
turbances present in severe purulent cases, namely, chills, fever, vomiting, 
and prostration. It is often quite difficult to differentiate between acute 
non-suppurative and acute suppurative otitis media, until the drum 
membrane ruptures. Indeed, both types of inflammation are due to 



ACUTE CATARRHAL OTITIS MEDIA 677 

infection, one undergoing resolution before suppuration, and the other 
passing into the suppurative stage. 

Intracranial complications never occur in acute non-suppurative 
otitis media, and somewhat rarely in the acute suppurative variety. Such 
complications occur more often in the chronic type, with acute exacer- 
bations. 

The exudate has a tendency to become organized into adhesive fibrous 
bands, hence it is very important that their absorption should be has- 
tened as much as possible. The air douche, by means of the Politzer 
bag and the catheter, should be used to clear the middle-ear cavity of the 
exudate, or at least to spread it over a larger surface, thereby reducing 
the amount of exudate at any one point. The inflations should be 
repeated from time to time until the ear is free from the exudate, as shown 
by the auscultation tube. 

Infants often have acute otitis media of very short duration, prob- 
ably of pneumococcal origin. Intestinal disturbances in infants are often 
accompanied by ear infection, and an examination of the ear should 
always be made. The exanthematous fevers of childhood are common 
causes of middle-ear infections, which in later years result in many 
deaths from meningitis, sinus thrombosis, brain abscess, etc. Great pains 
should be taken in these diseases to keep the nose and epipharynx clean 
during the fever. Scarlet fever and measles are especially destructive in 
this way. Diphtheria seldom invades the middle ear. 

Acute tuberculous otitis media is seldom accompanied by pam. This 
is in striking contrast to other types af acute infection. If an acute tuber- 
culous otitis media begins with pain and other symptoms peculiar to the 
ordinary acute suppurative otitis media, the prognosis is much more 
favorable than in the non-painful variety. 

Acute otitis media occurring during diabetes is not of diabetic origin. 
The occurrence of the two diseases is accidental. The diabetic disease, 
however, gives rise to constitutional disturbances which favor the long 
continuance of the ear discharge. 

Neglected cases of chronic catarrhal otitis media result in shrinking 
and atrophy of the mucous membrane, or adhesions may form, thus 
causing permanent loss of hearing. Ankylosis of the ossicles, or adhesive 
processes may bind the ossicles together, or to the contiguous walls of the 
cavum tympani. 

Sjnnptoms. — The symptoms of this disease vary according to the 
period of time which has elapsed since the onset. At the beginning 
they are much more pronounced than they are after a few days, when 
the more acute inflammatory process has begun to subside. 

1. The onset of acute otitis media is usually signalized by a slight 
chill, which is quickly followed by a temperature ranging from 99° to 
102°. The fever is, however, of such slight character in most cases that 
the attention of the patient is not usually attracted to it. The symptom 
which quickly develops, and which should demand the attention of the 
attending physician, is the pain, which may be characterized as a dull, 
boring, aching sensation, or it may assume a more acute type, and 



678 THE EAR 

become excruciating in its intensity. It is usually intermittent or 
throbbing in character, synchronous with the pulse beat at the wrist. 
It is due to the great swelling of the drumhead and mucous membrane 
of the middle ear, whereby the sensitive nerve filaments are injured by 
being put on the stretch with each arterial pulsation. It may also be due 
to the bulging of the drumhead outward into the meatus. There is a 
great amount of intercellular fluid thrown out at this stage of the disease, 
which together with the congestion of the bloodvessels renders the mucous 
membrane and drumhead very much thicker than normal. The contig- 
uous parts are thereby brought into apposition. 

In the first stage the drumhead is very red and thickened, the handle 
of the malleus being thereby hidden from view. Its surface may present 
the appearance of a ])iece of raw beefsteak, except that it is more velvety 
in its texture. The drumhead may or may not bulge into the ex- 
ternal meatus. This depends upon the amount of secretion within the 
middle ear. 

If the middle ear is filled with exudate, the drumhead is of necessity 
pushed outward. If, however, it is only partially filled, it may remain in 
its normal position or even be retracted. 

Auricular tenderness is sometimes present, especially over the tragus. 
The mastoid process may or may not be tender upon percussion or press- 
ure. Pressure over the mastoid antrum nearly always elicits tenderness, 
though it may be slight. 

Bone conduction is increased on the affected side. The lower tone limit 
is lost, while the upper tone limit is not affected except in those cases 
in which the labyrinth is involved. If the disease is unilateral, the Weber 
experiment lateralizes to the affected side. The Rinne test is usually 
negative in character. By the term negative I do not mean that it shows 
nothing, but that bone conduction for the tuning fork over the mastoid 
process is longer than by air conduction when the fork is held near the 
external auditory meatus. If the labyrinth is involved, bone conduction 
is diminished, and the Weber test shows the sound lateralized to the 
unaffected ear, while the Rinn^ test gives a positive sign. Labyrinthine 
involvement is, however, very rarely present in simple catarrhal otitis 
media. 

2. The second stage of this disease is characterized by the disappear- 
ance of the pain, fever, and redness of the drumhead. The entire con- 
gestive phenomena are lessened in intensity, hence the drumhead and 
mucous membrane are less thickened and swollen. The drumhead, 
instead of being beefy, or purplish red in color, is yellowish or greenish 
in tint. The change in color may be explained by the fact that there is 
less blood in the drumhead, and the pale, slightly greenish secretion in the 
middle ear is seen through it. The greenish, yellowish color often gives 
rise to the idea that there is pus in the middle ear. This error need not 
be made if the two conditions are carefully studied. 

Another symptom of considerable significance is the presence of a 
dark wavy line (Fig. 308) extending in a nearly horizontal direction across 
the drumhead. This line, which is 1 to 2 cm. in diickness, is due to the 



ACUTE CATARRHAL OTITIS MEDIA 679 

peculiar refraction of light at the junction of the viscid secretion and the 
air in the tympanic cavity. If it is below the umbo, it is usually concave 
on its upper surface; whereas if it extends above the umbo, it is usually 
composed of two concave surfaces. The line will be higher or lower on 
the face of the drumhead according to the amount of secretion in the 
middle ear. If the middle ear is completely filled, the line will not be 
visible. 

The position of the head determines the direction of the line, as the 
fluid gradually seeks the level of the new position (Fig. 369). The viscid 
nature of the secretion and the narrowness of the tympanic cavity inter- 
feres with the rapid change in the position of the secretion. The line is 
not visible, as a rule, on account of the great thickness and congestion of 
the drumhead. 

Another symptom is the presence of oval or round rings (Figs. 368 and 
369), which are due to the air bubbles in the viscid mucus. They may 
extend above the dark line, heretofore described, or they may be within 





Fig. 368. — Right membrana tympani showing mucus secretion and air bubbles after tympanic 
inflation. 

Fig. 369. — Right membrana tympani with mucus secretions and air bubbles after tympanic 
inflation, the patient having just arisen from the prone position. 

the field of the mucus itself. They may be single or multiple. After 
tympanic inflation the line disappears, while the entire field of the 
drumhead is occupied by the air bubbles. After several hours they will, 
in part, have disappeared, and the line will have returned. 

Aural auscultation, if used during the process of tympanic inflation, 
shows the presence of moist rales, due to the air passing through the 
viscid mucus. They are very dift'erent in character from the soft blow- 
ing murmurs heard during inflation of the normal ear. 

The first inflation may not be successful, as the Eustachian tube is 
filled with viscid mucus, hence it should be repeated several times. 
The diagnostic tube should always be used in performing tympanic 
inflation. 

The membrana tyin])aiii may or may not bulge into the auditory 
meatus, as this dejxMids upon the amount of secretion within the middle 
ear. When it bulges into the meatus it is a positive indication that 
paracentesis, or incision of the eardrum, should be performed. To 



680 THE EAR 

neglect to do this subjects the patient to unnecessary pain and to 
spontaneous perforation of the membrane. Spontaneous perforation 
should not be allowed to occur, as the perforating process is due to 
necrosis. Not only is irreparable damage thus done to the drumhead, 
but other parts are subjected to pressure and to possible ulceration and 
necrosis. 

Incision of the membrana tympani should, therefore, be done early, to 
prevent great destruction of tissue and to promote the reaction of inflam- 
mation. The incision does not result in scar tissue, which usually follows 
spontaneous rupture of the drumhead. 

It should be made at the most bulging portion, and should be crucial or 
V-shaped in character. Simple paracentesis, while often recommended, 
is not sufficient for free drainage of the tympanic cavity. The incision 
should be from ^ to | inch in length. The crucial or curved incision 
forms a slight flap which permits a larger opening for the discharge of 
the tympanic contents. If the incision is made straight and the drumhead 
is tense, the aperture for the discharge of the secretion is very small; 
consequently, it is recommended that it be made V- or crucial-shaped. 

Bone conduction is increased and the Weber and Rhine experiments give 
the results described under the onset of the disease. These tests should 
be made to determine, at the earliest possible moment, whether the 
labyrinth is involved. 

Diagnosis. — The pain and objective symptoms are sufficiently char- 
acteristic to render the diagnosis easy in most cases. Should there be 
any doubt, the middle ear should be infiated and observation made 
through the diagnostic tube, as to the character of the rales present. 
The appearance of the bubbles and the disappearance of the dark line 
will, when visible, also aid in arriving at a correct diagnosis. 

Prognosis. — This is favorable or unfavorable according to the period 
at which treatment is instituted for the relief of the disease. If the 
case is seen early and appropriate remedies are used, favorable results 
will follow in nearly all cases. If, however, the case is allowed to run on 
for some time before treatment is commenced, the prognosis is not so 
favorable. Changes of considerable importance may have taken place, 
such as adhesions of the contiguous parts, and ulceration in the super- 
ficial portions of the mucous membrane. 

There are certain conditions which render the prognosis less favorable, 
such as general constitutional diseases, as syphilis, tuberculosis, anemia, 
etc. It is obvious that if the diseases of the nose, epipharynx, and 
fauces, which predispose the patient to the primary attack, are present, 
there will be greater difficulty in effecting a favorable termination 
of the case, and when it seems to have been cured there may be sudden 
recurrences. 

The duration of the acute type varies from one to six weeks, although in 
some cases it may be aborted in one or two days. The pain, which is one 
of the firsts sym[)toms to appear, is also one of the first to subside. The 
redness of the drumhead and the swelling of the mucosa next subside, 
after which the hearing power begins to return. Later on the tinnitus 



ACUTE CATARRHAL OTITIS MEDIA 681 

passes away. This symptom, however, often remains for several weeks, 
and in those cases which merge into the chronic form it becomes a perma- 
nent symptom. 

Treatment. — There are several influences]to be considered in the treat- 
ment of acute catarrhal middle-ear inflammation, as we have shown in 
the study of the etiology that the causes are various and sometimes quite 
complicated. We are often called upon to relieve the patient of the pain 
or even of the acute inflammatory process, but we are not so frequently 
asked to treat the conditions which, if removed, would prevent a recur- 
rence of the disease. This cannot be done without giving attention to the 
epipharyngeal and faucial conditions which exert such a great influence 
in its production. The treatment should, therefore, be addressed to the 
relief of the acute inflammatory process in the middle ear and the upper 
respiratory tract in general, as well as to the complete removal of the 
morbid conditions of the nose, epipharynx, and fauces which made the 
disease possible. The first duty of the attending physician is, of course, 
to allay the pain as quickly as possible. 

So many remedies and methods of treatment have been proposed for 
this purpose that it is bewildering to look over the literature upon the 
subject. I will not, therefore, enter into any detailed description of all 
the methods of treatment that have been suggested, but will limit my 
remarks to those which have been the most successful. 

General or hygienic treatment should first of all be considered, as 
the proper care of the patient will largely influence the progress of the 
disease. He should be kept in the house during the acute stage, and if 
fever is present he should remain in bed. The room should be well 
ventilated and exposed to sunshine. His food should be simple and 
nourishing, such as is usually given to patients in hospitals. The bowels 
should be kept well regulated with saline cathartics, while alcoholic 
beverages and tobacco should be forbidden. A light pledget of cotton 
should be kept in the external meatus to protect the drumhead and the 
middle ear from air currents. 

Paiji, being the most prominent subjective symptom, should receive 
appropriate treatment at once. It is often so excruciating that the patient 
is very restless. A mixture of equal parts of carbolic acid, glycerin, and 
the hydrochlorate of cocaine may be dropped into the external meatus, 
where it will, in most cases, afford relief within a few minutes. A mix- 
ture of laudanum and oil in the external meatus is not to be recom- 
mended as of very great value. If there is virtue in the mixture at all,, 
it is due to the warmth or protection it affords to the exposed and inflamed 
membrane. It is usually advised that it be used after warming it in the 
bowl of a teaspoon. 

Another remedy of value for the relief of pain as well as of the conges- 
tion is a 12 per cent, solution of carbolic acid in glycerin (Andrews). 
While this solution does not have as great anesthetic })ower as the one 
first recommended, it nevertheless aids materially in allaying the pain. 
The remedy which I have often used to allay earache is the fumes of 
chloroform blown into the external meatus. This may be done in various 



682 THE EAR 

ways, perhaps most conveniently with a pipe, in the bowl of which 
there is a small piece of cotton upon which a few minims of chloroform 
are dropped. The stem of the pipe should be placed to the meatus, 
while the bowl is placed to the mouth of the operator. 

The fumes may thus be gently blown into the external auditory meatus 
and usually afford relief in a very few seconds or minutes. Leeches 
applied to the tragus, or posterior to the auricle, also relieve the pain and 
promote the reaction of inflammation. 

Cold packs and compresses may be applied over the ear for the same 
purpose, although their effect is neither so good nor so pronounced. 
Hovell recommends the use of blisters or plasters over the mastoid pro- 
cess, though they are liable to produce ugly sores. Their value is due 
to the fact that they promote the reaction of inflammation. There are, 
however, other remedies which are more efficacious and which do no 
harm. The same may be said in regard to the use of warm poultices, as 
they macerate the parts and render them less able to resist the infection 
present in the middle ear. Perforations of the drumhead have un- 
doubtedly been induced by their application. The leukodescent light 
from a 500 candle-power lamp exerts a favorably influence upon the 
inflammatory process by promoting the reaction of inflammation, 

T5nnpanic Inflation. — During the past few years the literature has 
shown a bias favorable to the use of glycerin and carbolic acid for the 
cure of acute middle-ear inflammations. The remedy is a valuable one, 
but it does not meet all the indications, especially those which arise from 
the great tumefaction and adhesive processes. It is important, therefore, 
that tympanic inflation be performed at frequent intervals, in order to 
increase the air pressure within the middle ear, thereby separating the 
inflamed surfaces. 

In this way the adhesions are 'prevented, or, if formed, they are broken 
down and a long train of symptoms and impairment of the auditory 
function, so often seen in the dry or adhesive types of chronic ear disease, 
are averted. The inflation serves a very usefid purpose in freeing the 
tympanic cavity from secretions and in maintaining the patency of the 
Eustachian tubes. 

If the drumhead is very red and swollen, and there is great pain, the 
air douche should be used with great caution, as there is danger of perfor- 
ating it. Inflation should therefore be chiefly limited to the second 
stage of the disease, when it should be performed at frequent intervals. 
The patient should be provided with the Politzer air bag and instructed 
in its use. The frequency with which it should be used depends upon 
the rapidity with which the secretions are formed. In ordinary cases 
it shoidd be used at intervals of one to three hours. In this way the 
tympanic cavity and Eustachian tubes are kept free from secretions. 
The hyperemia is reduced by the increased air pressure, and the adhe- 
sions between the ossicles and tympanic walls are prevented 

Inflation is most effective when performed through the Eustachian 
catheter, but this, of course, can only be done by the attending physician. 
If the case requires more frequent inflation than can be conveniently 



ACUTE CATARRHAL OTITIS MEDIA 



683 



given by the physician, dependence must be placed upon the use of the 
Pohtzer air bag. 




The application of the aitificial leech to the mastoid process The cord is drawn, thus rapidly 
rotating the circulai knife applied to the skin of the mastoid process. 

Leeching over the mastoid process and in front of the tragus is often 
attended by prompt and marked improvement. Leeches should be more 
frequently used than they are in acute inflammatory processes of the 



Fig. 371 




Tlio exhaust pump withdrawing blood through the circular incision. 



middle car and mastoid process. Tlierc is no other rcMuedial measure 
that acts as promptly. The artificial leech, as shown in Figs. 370 and 
371, may be used instead of live leeches. 



684 



THE EAR 



Pneumomassage is a valuable adjunct to the treatment of the later 
stages of acute inflammations of tlie middle ear. During the very acute or 
first stage its use is not tolerated on account of the pain and great swelling 
present. Later it is valuable, as it lessens the vascular and lymphatic 
engorgement of the tissues. It also prevents ankylosis of the ossicles. 
It should be applied only with such a length of piston stroke as gives rise 
to no pain. Should it be used in such a way as to cause pain, it may 
increase the inflammatory process or rupture the drumhead. The prin- 
ciple is the same as that relating to the use of massage in any other part 
of the body — namely, that it should be used with such force as not to 
produce contusion or injury to the tissues. The form of pneumomas- 
sage best adapted for use in these cases, at least in the secondary stage, 
is alternating compression and rarefaction of 
Fig. 372 the air in the external meatus. With the 

Victor massage apparatus and the Pynchon 
modification of the pump (Fig. 15) any variety 
or character of compression and rarefaction 
that, may be desired can be produced. It 
is, therefore, a good instrument for use in 
these cases. If such an instrument is not 
available, reliance should be placed upon the 
use of Siegle's otoscope (Fig. 372) or a simple 
^^^Mj rubber tube with a suitable meatal tip through 

^^ which alternating compression and rarefac- 

tion may be produced with the mouth. Or 
the Delstanche masseur (Fig. 14) may be 
used. These instruments have the advantage 
of being under the perfect control of the 
operator, while they have the disadvantage of 
imposing upon him the necessity of admin- 
istering the treatment from one to fifteen min- 
utes, as the case may require. I cannot agree 
with some authors regarding the massage 
machines, which are propelled by an electric motor, as being im- 
pressive pieces of machinery, which have but little actual value as 
therapeutic agents. I know, from ten years of actual experience in 
their use, as well as in the use of the hand apparatus, that better 
results are obtained by the judicious use of the so-called "machines" 
than I have ever been able to get with the simpler devices. However, 
the hand instruments are especially well adapted for use in acute catar- 
rhal cases, as pneumomassage is not usually used for so long a time at 
each treatment. Pneumomassage is of little value in well-advanced 
adhesive processes, nor is any other mode of treatment except surgical 
treatment in selected cases. 





Siegle's otoscope. 



CHRONIC MOIST CATARRHAL OTITIS MEDIA 685 



ACUTE INFLAMMATION OF THE EXTERNAL ATTIC OF THE 
TYMPANIC CAVITY (POLITZER). 

The external attic is sometimes the seat of a circumscribed acute 
inflammation. The exudate is thrown out into Prussak's space (Fig. 
334) and partly into the spaces formed by the folds of mucous membrane 
between the malleo-incudal body and the external tympanic wall. 

The disease is characterized by slight pain and deafness, with a tumor 
or blister-like formation on the anterior portion of Shrapnell's mem- 
brane (membrana flaccida) ; or if the posterior spaces are involved, the 
projection forms upon the posterior portion of the flaccid membrane. 

Etiology. — The exciting cause of|this rather rare condition is the same 
as in acute otitis media, namely, the specific bacteria of exanthematous 
fevers,"^epipharyngitis, and influenza. The predisposing causes are 
those conditions which give rise to obstructed drainage through the 
Eustachian tube. Sea bathing or cold solutions in the external canal 
act as predisposing causes. It is probable that the infection usually 
reaches Prussak's space through the Eustachian tube, although it is 
possible for it to pass through the Rivinian foramen. 

Symptoms. — In the mild form there is a feeling of fulness in the middle 
ear, slight pain, deafness, and tinnitus.. The membrana flaccida is red- 
dened and bulging, or it may be yellow at its prominent portion. The 
upper wall of the meatus near the drumhead is red and slightly swollen. 
The membrana tensa usually appears normal. The process may run its 
course in a few days. 

In the severe form the reactive symptoms are more pronounced, the 
hearing being temporarily more disturbed, although there is usually no 
permanent loss of hearing. The membrana flaccida is much more bulg- 
ing, often completely covering the short process and handle of the malleus. 
The course in the severe form is prolonged, but may finally result in 
complete recovery. 

Treatment. — The treatment is the same as for acute otitis media and 
acute suppurative otitis media, except there is no need for tympanic 
inflation, as there is no deafness from swelling of the mucosa of the 
middle ear and Eustachian tube, and the tension of the membrana 
tensa and ossicles is not disturbed. 



CHRONIC MOIST CATARRHAL OTITIS MEDIA. 

This disease is characterized by intermittent or remittent deafness 
and tinnitus aurium. It may follow acute catarrhal otitis media, or it 
may come on without any previous history of acute disease. In some 
cases the deafness is progressive, while in others it extends by leaps and 
bounds. The patient often makes the statement that he hears very well 
until after exposure, after which he is much more deaf. The acuity of 
his hearing is usually less during the damp, cool weather of late autumn 
and early spring. 



686 THE EAR 

Etiology. — The study of the etiology, as given under Acute Catarrhal 
Otitis Media, in a large measure applies to this disease. Therefore a 
detailed statement is not given in this connection. It is sufficient to 
state that in most instances the chronic disease is an immediate result 
of the acute inflammation. This is especially true in those cases which 
are not treated early or in an appropriate manner. It is also especially 
liable to follow the acute type in those cases in which there has 
been previous chronic rhinitis, epipharyngitis, and obstruction of the 
Eustachian tubes. The obstruction of the tubes by adenoids, epipharyn- 
geal catarrh, nasal and accessory sinus disease, etc., undoubtedly forms 
one of the chief factors in the production of the disease. 

Attacks of one or more of the exanthematous fevers act as an exciting 
cause of both the acute and the chronic catarrhal inflammation. This 
also causes an increase of the hyperemia of the lymphoid tissue of the 
epipharynx and the Eustachian tubes. The patency is thereby lessened, 
while the presence of adenoids gives rise to a epipharyngitis, which 
tends to extend through the tube to the middle ear by continuity of tissue. 
There is a close relationship between adenoids and catarrhal processes in 
the middle ear, hence it is important that every case should be examined 
as to their presence. If present, appropriate measures should be insti- 
tuted for their removal. 

Enlarged or diseased faucial tonsils also exert a positive influence on 
disorders of the middle-ear cavity. The presence of foul and microbe- 
laden material in the cr^'pts of the tonsils is very detrimental to the middle 
ear, as it gives rise to constant irritation and inflammation of the mucosa 
of the epipharynx and Eustachian tubes. 

The presence of the toxins from the microbes is probably one reason for 
the irritation. All diseased conditions of the tonsils are likewise inimical 
to the integrity of the auditory apparatus. When the pharyngopalatine 
arch (posterior pillar) of the fauces is adherent to the tonsil, the palato- 
pharyngeus muscle is subjected to irritation and inflammation; its fibers 
undergo degenerative changes, and its power to regulate the patency of 
the Eustachian tube is impaired. 

Nasal diseases of an inflammatory t}^e may extend to the epipharynx, 
from thence into the Eustachian tubes and the middle ears; hence, acute 
and chronic forms of rhinitis are active agents in the production of catar- 
rhal otitis media. 

Obstructive diseases of the nose which lead to rarefaction of the air 
posterior to the obstruction (during the act of inspiration) induce con- 
gestion of the nasal and epipharyngeal mucosa, and have a direct effect 
upon the congestion of the mucosa of the Eustachian tubes and the mid- 
dle ears. This, after a time, results in retrograde changes of an inflam- 
matory type, as chronic catarrhal otitis media. It is, therefore, apparent 
that nasal or epipharyngeal conditions which markedly depart from the 
normal may lead to catarrhal processes of the tympanic cavity. '' ' 

The influences of climate, age, and sex have more or less to do with the 
causation of the disease. The climatic conditions found in most places 
in the temperate zones, and especially near great bodies of water, are 



CHRONIC MOIST CATARRHAL OTITIS MEDIA 687 

particularly aggravating to this class of cases. The disease is not one of 
young childhood, but appears more prominently in young or middle 
adult life. It is found in about equal proportions in males and females, 
although it is probably found more often among the males, as they are 
more exposed to the inclemencies of the weather. 

The disease is usually bilateral, although in a few instances it is uni- 
lateral. When unilateral it is more often found in the left ear. 

The use of alcohol and tobacco lowers the resistance of the mucous 
membrane and undoubtedly favors the production of the disease. 

Symptoms. — Subjective Symptoms. — The chief subjective symptoms 
are deafness and tinnitus aurium. In addition to this, there is a feeling 
of fulness in the ears. 

Giddiness is present in a certain number of cases, but is by no means 
a constant symptom. 

Deafness. — This is the chief symptom of the disease, and is usually 
the one which leads the patient to seek relief. In quite a number of cases, 
however, the tinnitus is so much more annoying than the deafness that 
relief is sought on this account. The deafness may at first be so slight 
and so insidious in its progress that the patient is unconscious that his 
hearing is defective. He says his inability to understand what is said to 
him is explained by the slipshod way in which he is spoken to. It is not 
uncommon for such patients to feel offended when it is intimated that 
they do not hear well. They are very apt to reply that they can hear 
when they are spoken to in the proper manner. After a time they notice 
slight subjective noises, after which it is only a question of a few months 
until they become conscious that their hearing is defective. In some sub- 
jects, however, the progress is not so insidious as that just described. On 
the contrary, it may be very rapid, then after a time seemingly remain 
stationary for months or years. The deafness may again suddenly become 
worse, and so continue throughout life. The rapid progress made is not 
indicative of the severity of the inflammatory process, but rather points to 
the fact that certain vital parts have become involved, thereby limiting the 
sound-conducting function of the auditory apparatus. If the changes 
which take place in the middle ear are limited to the mucosa of the tym- 
panic cavity, the deafness is slighter and less rapid in its progress; 
whereas if the ossicular chain, the round or the oval windows are involved 
in a marked degree, the deafness comes on suddenly and is more pro- 
nounced in character. It is important to bear this in mind, as otherwise 
it is not possil^le to understand why in one case of simple chronic catar- 
rhal otitis media there is such slight deafness, whilst in another there is 
marked and sudden increase in the deafness. 

TinnHus aurium is a symptom which is almost constantly present 
in greater or less degree. When it is present the ])atients are often very 
much annoyed by it. Their sleep and rest at night are interfered with. 
They sometimes become nervous and hysterical, and if relief cannot be 
afforded they are apt to become morose. The noises in the ears and the 
head assume almost any variety of sounds or tones, ranging from simple 
pulsating murmurs to thundering noises, or reports like the shot of a 



688 THE EAR 

pistol or a cannon. In many they are of a whistling or singing character, 
whilst in others there is a buzzing, or dripping of water. They may be 
musical or simply noise. They may be mild or very intense. They may 
be constant, intermittent, or recurrent. It is doubtful if the noises in 
simple catarrhal otitis media ever assume the form of spoken language. 
Cases which seem to hear voices and to receive messages and revelations 
probably have a central lesion of the cortex. The brain may otherwise 
be practically normal, so that the psychological phenomena referred to the 
organ of hearing may be the only evidence that the patient has departed 
from the normal mental state. The case of Joan of Arc, which has 
excited so much historic and romantic interest, possibly belonged to this 
class. 

In some cases the tinnitus is synchronous with the heart beat, whilst 
in others it is very irregular in rhythm. Various explanations have been 
given to account for those cases in which the noises are synchronous with 
the cardiac pulsations, none of which seem to explain them. The most 
probable explanation is that in some way or other the vibratory thrill of 
the arteries of the tympanum is imparted to the membrana tympani and 
the ossicular chain in such a way as to be transmitted to the labyrinth, 
from whence the sensation is conveyed through the auditory nerve to 
the brain centre, where it is appreciated as sound. The tinnitus may 
be very high or very low in pitch, and in either case it is indicative 
of an advanced stage of the disease. If, on the other hand, they are 
medium in pitch, they are indicative of a less advanced stage. The 
state of the general health very materially influences the degree and the 
character of the noises. When the patient is fatigued they are worse. 
If he is affected by some disease which lowers his vitality they are worse. 
I have seen patients who were the subjects of neurasthenia, in whom the 
pulsating noises were very pronounced. Some of these patients did not 
have ear disease, the pulsating tinnitus being only one of the symptoms 
peculiar to their nervous and anemic condition. In others, who were 
subject to catarrhal otitis media, the tinnitus was very much aggravated 
by the neurasthenia. 

The excessive use of alcohol and tobacco increase the intensity of the 
noises, and may even cause pulsating tinnitus, synchronous with the 
cardiac pulsations, even in persons who are not subject to otitis media. 

Autophony consists of a vibration and echo-like reproduction of the 
patient's own voice. This symptom is sometimes present in the moist, 
but more particularly in the dry type of catarrh. It is most commonly 
found in those cases in which there is an undue patency of the Eustachian 
tube or a stenosis of the same. 

The 'paracusis of Willis, or "paracusis Willisii," is a symptom which 
is present in well-advanced cases. When present it is an unfavorable 
sign, and should lead to a very guarded prognosis. It consists of an 
al)ility to hear better in the presence of noises than in a quiet place. 
Thus patients will hear better in a street car or train than they do 
in the quiet of a country home. It is a probable indication that the 
mobility of the ossicles is interfered with by ankylosis or adhesive pro- 



CHRONIC MOIST CATARRHAL OTITIS MEDIA 689 

cesses, or the swelling of the mucous membrane of the tympanic walls, 
and that covering the ossicles may be so great as to interfere with their 
mobility, thus giving rise to the symptoms. 

Objective Symptoms. — The drumhead should be examined with refer- 
ence to its position, color, lustre, and reflection of light. In infants its 
position is normally at a very obtuse angle to the superior wall of the 
meatus, while in adults the obtuseness of the angle is much less pro- 
nounced. In other words, in adults the drumhead is more nearly at right 
angles to the axis of the external meatus than it is in very young children. 
In infants it is so nearly parallel with the superior wall of the meatus 
that it seems to be a continuation of it. As the tympanic ring develops 
it rapidly assumes a more erect position, until it finally has that which it 
maintains throughout adult life. Its position will, therefore, depend 
upon the age of the patient and upon the completeness with which 
development has taken place. 

If the Eustachian tube is closed for any reason and the air is obstructed 
from the tympanic cavity the drumhead will be drawn inward or retracted. 
This gives rise to a change in the reflecting surface of the drumhead, 
and consequently modifies the refiection. The cone of light, which is 
normally present with the apex toward the lower end of the handle of 
the malleus while its base is directed downward and forward toward the 
periphery, will either diminish in size, break into one or two whitish spots, 
or entirely disappear. This symptom is, in most cases, indicative of 
retraction of the drumhead. If there are adhesions binding it to the pro- 
montory or other portions of the inner tympanic wall, the surface of the 
drumhead will present an uneven appearance, especially after inflation. 
At the points of adhesion it will appear whitish in color, whereas in the 
non-adherent portions there may be a slight reddish color, due to the 
reflection of light from the red mucous membrane of the inner tympanic 
wall. 

The color of the drumhead has been variously described as of a pearl- 
gray, pinkish-gray, bluish-gray, or yellowish-gray membrane. Some of 
these observations have been made upon cadavers, in which the normal 
colors were not present. By the use of such lights as are now at the com- 
mand of most practitioners, the healthy membrane uniformly presents a 
pearl-gray color, with here and tliere a slight admixture of orange and 
purple. The orange is due to the red reflex of the inner tympanic 
wall, though this is now regarded as a sign of spongifying. 

Calcareous spots are sometimes found on the drumhead, even when 
there is no history of a previous suppurative process. They are undoubt- 
edly the remnants of former inflammatory changes. 

In the normal drumhead there is a distinct luminous lustre (Fig. 373) , 
which is so modified in chronic catarrhal otitis media as to materially 
lessen its smoothness and ])rilliancy. The memln-ane appears whitish 
and velvety in texture in proportion to the amount of thickening it has 
undergone. The redness and the pinkish-gray color will have disap- 
peared l)ocaiisc the vascul;ii-ily and transparency of the drunihcud are 
diminished. 
44 



690 



THE EAR 



The appearance of the drumhead may be modified by the presence of 
tympanic secretion. The dark Hne spoken of under Symptoms of Acute 
Otitis Media, which marks the upper limit of the secretion, may be present 
in these cases. Unless the thickening of the drumhead is so pronounced as 
to interfere with its transparency, the bubbles of air spoken of in the same 
connection may also be seen. The presence of an appreciable amount 
of mucus in the middle ear is usually a sign of a subacute attack, but 
the drumhead may be so thickened that it is not easy to discern it. The 
opacity of the mucus increases with its viscidity, hence some estimate may 
be made by this observation as to the character of the secretion present. 
In those cases in which the drumhead is atrophied in circumscribed 
areas the secretion may be clearly seen at these points, while at the more 
opaque and thickened areas its presence can- 
FiG. 373 not be detected. If there is a large quantity of 

mucus in the middle ear the drumhead may 
bulge outward in its entirety if non-adherent, 
or in part if there are adhesions. 

Prognosis. — The curability of chronic 
otitis media is somewhat in proportion to 
its chronicity and the pathological changes 
in the essential structures of the tympanic 
cavity. If the disease is of recent occurrence 
and the morbid changes are slight, the prog- 
nosis is quite favorable. If the disease is of 
long standing and pronounced degenerative 
changes in the mucous membrane covering 
the ossicles or the membrana tympani have 
occurred, the prognosis as to the restoration 
of hearing is not good. 

Treatment. — The treatment should take 
two general factors into account, namely, the 
etiology and the pathological changes present. 
If the chronic disease is the offspring of an acute catarrhal process, the 
causes of the acute disease should be determined and eradicated if pos- 
sible. If the patient has been subject to either of the forms of rhinitis or 
sinuitis, he should be treated accordingly. Ethmoiditis and sphenoiditis 
are particularly responsible for otitis media. Too little attention has 
been given to these cavities in the treatment of ear disease. I have seen 
a number of cases in which the ethmoidal and sphenoidal disease 
was the chief cause of otitis media. Appropriate treatment, surgical 
or otherwise, addressed to the sinuses, speedily relieved the ear 
disease. The symptoms of mild chronic ethmoiditis and sphenoiditis are 
not so obvious as to attract the attention of the physician to them unless 
he has had unusual opportunities for making such observations. The 
patient, perhaps, only complains of a "dropping" into the throat. An 
examination of the epipharynx and posterior choanse may show a muco- 
purulent secretion flowing over the posterior end of the middle turbinal 
on to the posterior wall of the epipharynx. Anterior rhinoscopy shows the 




A normal membrana tympan 
of the right ear as viewed througl 
a speculum. 



CHRONIC MOIST CATARRHAL OTITIS MEDIA 691 

middle turbinal closely approximated to the septum. The divulsion of 
the middle turbinal away from the septum, or its partial or complete 
removal, will often exert a very favorable influence upon the course of the 
aural disease. In some cases it may be necessary to make a total exen- 
teration of the ethmoidal cells and to remove the anterior wall of the 
sphenoidal sinus. 

If the ear disease is due to tonsillar disease, the treatment should be 
directed to it, total ablation of the tonsil with its capsule intact being the 
best method of procedure. 

Adenoids and inflammatory processes of the epipharyngeal mucous 
membrane, if present, should be treated. The presence of adenoids often 
perpetuates a chronic epipharyngitis, hence the removal of the adenoids 
exerts a favorable effect upon the epipharyngitis. As the pharyngeal 
inflammation extends by continuity of tissue to the Eustachian tube and 
middle ear, it is obvious that the removal of the adenoids or their remnants 
will exert a very favorable influence upon the course of the ear disease. 

When the structures adjacent to the Eustachian tube have been freed 
from morbid processes, the ear may be treated for the removal of the 
local morbid lesions and to restore the mechanical equilibrium, which is 
so essential to normal hearing. 

The tympanic cavity should be inflated for three purposes, namely: 
(a) To force the secretions from the tympanic cavity and Eustachian 
tube; (h) to restore the equilibrium of air pressure on the two surfaces 
of the membrana tympani; and (c) to improve the arterial and lymphatic 
circulation of the lining mucous membrane. (See Principles of Tym- 
panic Inflation, and Methods of T}anpanic Inflation.) 

The air should be rarefied in the external meatus with Del- 
stanche's rarefacteur after each inflation, as this increases the passive 
hyperemia of the inflamed membrane and promotes the absorption of 
the inflammatory exudates. It also reduces the annoying tinnitus 
usually present in this disease. 

The mechanical removal of the secretions from the middle ear may be 
accomplished by paracentesis (Schwartze) or incision of the drumhead 
and by suction applied to the external meatus. This procedure is only 
indicated when the secretions are so heavy or tenacious as to resist being 
discharged through the Eustachian tube, or the tube is obstructed by 
disease. The incision should be long and curved (see Incision of the 
Membrana Tympani), as in acute suppurative otitis media before per- 
foration. 

Even then the secretions will not appear in the meatus for several 
minutes or hours, unless the middle is forcibly inflated or suction is 
applied to the meatus. The meatus should be lightly packed with a strip 
of gauze for a few hours, at the end of which time it will be saturated 
with the secretion. After thoroughly cleansing the meatus with a cotton- 
wound applicator it should ])e refilled with gauze. The incision usually 
closes in from one to three days, and should be re])eated if marked 
bulging of the membrana tympani reappears. 

When the secretions are more serous in character drainage is facili- 



692 THE EAR 

tated, as suggested by Politzer, by having the patient take a swallow of 
water in his mouth, then inclining his head well forward and somewhat 
toward the opposite side, thereby causing the axis of the Eustachian 
tube to stand perpendicular to the plane of the earth. The patient's 
head should be held in this position for two or three minutes, to allow 
the secretions in the middle ear to gravitate to the tympanic end of the 
Eustachian tube. At the end of this time the patient should swallow the 
water held in his mouth, thus opening the pharyngeal end of the tube and 
allowing the secretions to flow into the pharynx. As Politzer says, shortly 
after this procedure the membrana tympani presents a grayish color, 
whereas before it the membrane was yellowish in co or. 

The passive hyperemia of the mucous membrane of the Eustachian 
tube gradually subsides during the treatment by inflation, and the 
patency of the tube is gradually restored. The secretions also diminish 
in quantity and in consistency, and the tube becomes adequate to carry 
on its drainage and ventilating functions. 

In rare instances the swelling of the tube persists, and it may become 
necessary to make local applications of weak zinc, silver, ammonium 
chloride, ol. eucalyptus, and the vapors of menthol to the tube. Gener- 
ally speaking, these remedies are of slight value, a better procedure 
being the administration of hepatic and saline aperients. I have found 
mechanical vibrations behind the angle of the inferior maxilla very useful 
in opening the Eustachian tube when it resists the usual methods. 

A.. H. Buck has recommended the introduction of medicated bougies. 
Politzer uses a small violin string cut into suitable lengths for this purpose. 
They are soaked in a saturated solution of the nitrate of silver, dried, 
and introduced through a catheter as far as the isthmus tubae, and left 
there for from three to five minutes; from three to four applications often 
open the tubes. 



ADHESIVE PROCESSES IN THE MIDDLE EAR. 

Synonyms. — Sclerosis of the middle ear; otitis media catarrhalis 
chronica; dry catarrh of the middle ear; otitis media catarrhalis sicca; 
otitis media sclerotica; proliferous inflammation of the middle ear. 

Etiology. — ^The causes of adhesive processes in the middle ear are 
not fully imderstood. It is probable that several conditions are included 
under this title. Exudative catarrhs of the middle ear often seem to be 
attended by the formation of adhesive processes, and are often followed 
by their appearance. They sometimes appear without being preceded 
by a secretive or exudative catarrhal inflammation. The trophic centres 
or tracts seem to be at fault. The onset and progress of the disease are 
insidious and go on to pronounced deafness. The labyrinth is quite 
often involved, probably from the same trophic influences. The mucous 
membrane around the oval window is especially aft'ected, and the cica- 
tricial contraction of the fibrous bands often fixes the stapes firmly in the 
window. Atrophy, fatty and colloidal degeneration of the labyrinth often 



ADHESIVE PROCESSES IN THE MIDDLE EAR 693 

occur simultaneously or precede the sclerotic processes in the middle ear. 
The adhesive processes resulting from exudative catarrh of the middle 
ear are not attended by such pronounced deafness, and are marked 
by decided symptoms even in the early stages. In the trophic or 
insidious form symptoms do not usually manifest themselves until the 
disease is well advanced. 

The etiology may be summarized as follows : 

(a) Exudative or moist catarrh of the middle ear. There is some 
doubt in my mind as to the causative influence of moist catarrhs, as in 
children in whom it most frequently occurs the adhesive processes are 
rarely found. 

(b) Trophic disturbances affecting either the middle ear or labyrinth. 
It appears in some cases to affect the labyrinth first and extend to the 
middle ear. It is probable that both the middle ear and labyrinth are 
affected at the same time, although the symptoms may become manifest 
in one earlier than in the other. It is quite probable that hyperostosis or 
spongifying of the bony capsule of the labyi'inth is mistakenly diag- 
nosticated as an adhesive process. 

Pathology. — The adhesive processes may be classified as either diffused 
or circumscribed. The diffused type usually arises from an exudative 
chronic catarrh; the circumscribed type from trophic disturbances. 

According to Politzer, "the structural changes in the mucous mem- 
brane consist in partial or total transformation of the newformed round 
cells into fibrous connective tissue, interstitial hypertrophy of the mucous 
membrane with retrograde metamorphosis of the newformed tissue, 
shrinking, sclerosis, atrophy, and calcification." 

In those cases in which the secretions are still abundant the mucous 
membrane is hyperemic, spongy, or gelatinous, and yellow or bluish 
red in color. The surface is uneven and ragged in appearance. 

After the moist stage has subsided the membrane becomes smooth, very 
thick, and firmly attached. 

In the diffused or insidious type the changes seem to proceed from the 
periosteum to the epithelial surface of the membrane. The favorite 
location for the adhesive process in these cases is about the oval window 
(spongifying?). The gross appearance on inspection through an open- 
ing in the drumhead shows very little evidence of the true condition. The 
contraction and calcification take place in the deeper portions of the 
mucosa and fix the foot plate of the stapes in the oval window. 

In another class of cases niunerous fibrous bands form in the middle car. 
They may extend from the ossicles to the walls of the tympanum or from 
ossicle to ossicle; or they may extend from the wall to the drumhead. 
The ossicles are thus bound together, and the drumhead is drawn by 
contracting fibrous bands to the fixed walls of the middle ear. The nor- 
mal tension of the ossicular chain and drumhead is tluM-eby unbalanced, 
and serious interference with hearing occurs. 

Jnfdal life bands or folds of nuicous membrane exist in the same j>laces 
often o('CU})ied l)y fibrous formations in the adhesive process. They are, 
therefore, only perversions of an earlier embryonal formation. According 



694 THE EAR 

to Toynljee and von Troltscli the bands are sometimes transformed by 
calcareous deposits into bone-like processes. 

In addition to tlie foregoing changes, the articulations of the ossicles 
may be ankylosed by fibrous formations or by the deposit of lime 
salts. In either event the vibratory function of the chain of ossicles is 
impaired. 

The mucous membrane of the entire attic in rare cases undergoes 
calcification, and a partial or complete obliteration of the attic results. 

The changes in the Eustachian tubes are largely dependent upon 
whether the middle-ear disease is of the diffused (moist catarrh) or of 
the circumscribed variety. In the diffused type the tube is similarly 
affected, while in the trophic type it is usually normal. The lumen is 
obstructed in the diffused variety, while it is unaffected in the circum- 
scribed type. 

Both ears are affected except in rare cases. This, together with the fact 
that it rarely occurs in children, in whom moist or exudative catarrhs are 
most common,' rather discredits exudative catarrh as the cause. AMien 
it occurs in children it is usually easy to trace it to disturbances of 
nutrition, scrofula, etc. 

Symptoms. — It is convenient to study the symptoms under the (a) 
drumhead, (6) the Eustachian tubes, and (c) the subjective symptoms. 

(a) The drumhead is thickened, lustreless, and opaque. Areas of 
opacities more or less sharply defined may sometimes be seen. In some 
cases they are sharply defined, and appear as chalky white deposits, while 
in others they merge into the surrounding tissue with ill-defined borders. 
They are tendinous and gray in color. The spaces between the whitish 
deposits appear dark or bluish in color. 

The handle of the malleus appears less distinct and wider than normal 
on account of the thickened condition of the drumhead. The cone of 
light is shortened, irregular, or entirely broken. The handle of the mal- 
leus is drawn inward and backward, and is, therefore, foreshortened. 

The adhesive bands may be attached to the drumhead and cause cir- 
cumscribed retractions. The retracted areas may also be due to atrophy 
or to direct adhesions of the drumhead to the inner tympanic wall. 
They appear as rounded or oval depressions (Fig. 374). 

Schwartze called attention to a distinct reddish glimmer around the 
umbo as indicating a circumscribed inflammation (insidious type) 
around the oval window. In these cases the drumhead is usually normal, 
although it is occasionally opaque or atrophic. These cases are now 
generally recognized as hyperostosis of the bony capsule of the labyrinth. 

The external meatus is usually devoid of cerumen, although it may be 
covered by a dense brown secretion. 

(6) In the diffused variety the Eustachian tubes may be more or less 
obstructed by fibrous formations in their lumen. In the circumscribed 
variety they are usually normal. 

(c) The subjective symptoms vary according to the degree of involve- 
ment of the middle ear and labyrinth. They also vary with the location 
and character of the lesion. 



ADHESIVE PROCESSES IN THE MIDDLE EAR 695 

Perhaps the most common and most pronounced subjective symptom 
is tinnitus. If the disease is well advanced it is continuous, although its 
intensity varies with the atmospheric conditions and constitutional vigor 
of the patient. If tired, worried, or weakened from excessive alcoholic 
beverages or illness, they become more pronounced. The noises vary 
in character and intensity in different and in the same individual. 

Disturbances of hearing may appear simultaneously with the tinnitus, 
although the subjective noises usually appear first. The noises increase 
with the deafness, although in many cases they diminish until with com- 
plete deafness there are none. 

Pain is rarely present, although hyperesthesia acoustica is often a 
prominent symptom in the early stages of the disease. It is especially 
marked in the presence of shrill tones and loud speech. 

More or less giddiness and fulness in the head are experienced in the cases 
in which there is continuous tinnitus. In some cases the Meniere group 
of symptoms are present, especially when there is a sudden increase in the 
deafness. It is probably due to a sudden deposit of an exudate in the 
labyrinth. The giddiness is sometimes persistent, while in others it 
gradually disappears without apparent damage. Aprosexia or difficulty 
in fixing the attention is sometimes complained of. 

The hearing is disturbed in proportion to the interference of sound 
conduction to the oval window through the drumhead and ossicles and 
the degree of pathological changes within the labyrinth. The patient 
hears at greater distances at one time than at another, although the varia- 
tion is not as great as is observed in ordinary catarrhal otitis media with 
secretion. The condition of the patient influences the hearing to a marked 
degree. He hears better in the morning when vigorous than he does 
toward evening when weary. Mastication of the food temporarily 
increases the deafness. 

Hearing for speech may be very poor, while the finest variations in 
music may he distinguished^ or the falling of a small instrument may be 
distinctly heard (Politzer). 

Paracusis Willisii, or ability to hear better in a noisy place, as in a 
street car, than in a quiet room, is quite characteristic of this affection. 
It is my custom to ascertain in every case whether or not this symptom 
is present, as it gives a fair indication as to the prognosis of the dis- 
ease. It should not be assumed, however, that the patient cannot be 
benefited by treatment because this symptom is present. The ordinary 
treatment by inflations and massage will, however, usually fail to afford 
relief. More radical measures, to be described, will in some instances 
prove efFectual. 

The Course of the Disease. — The course of the disease is progressive, 
altliongli it is not sicady in its advancement. It rarely progresses by 
gradual increase in deafness, but goes by leaps and bounds. It often 
remains stationary for years and then suddenly becomes worse. It is 
always progressive, as it is due to degenerative pathological changes in 
tissues, as contraction, calcification, and ossification. These conditions 
are slow in dcvi^lopinent, on arfonnt of the nature of the ])athologi('al 



696 THE EAR 

process. They progress by leaps liecaiise the changes may involve por- 
tions of the tissue l)ut little concerned in the function of hearing, until 
finally it encroaches upon tissue intimately concerned in audition, and 
hearing suddeidy becomes impaired. This does not necessarily mean 
that the pathological process has suddenly increased, but that it has 
invaded functionating tissue. The disease rarely goes on to complete 
deafness. 

In the insidious or iropliic type of the disease persistent tinnitus, often 
of a most aggravated character, may exist for years without deafness. 
The trophic intersitial changes are chiefly about the fenestra of the vesti- 
bule (oval window). Finally, the foot plate of the stapes is ankylosed, 
and deafness becomes a pronoimced symptom. These cases are often 
mistaken for nervous tiunitus until the deafness sets in (spongifying) . 

Politzer says: "In the greater number of cases in which ankylosis of 
the stapes was observed postmortem, I found from the history of the 
patient that the decrease of hearing occurred after the existence of 
subjective noises for ten or fifteen years, and the progressive increase 
of deafness was very gradual. In these cases there was generally a 
marked negative Rinne, with sometimes lengthened and sometimes 
diminished duration of perception through the cranial bones; the latter, 
especially when the disease had existed for a long time, and in old 
age.'' 

When unilateral adhesive inflammation has existed for a long time and 
the other ear subsequently becomes involved, the progress in this ear is 
quite rapid, in contradistinction to the progress in bilateral involvement. 

In rare cases a change for the better takes place spontaneously. This 
may be permanent, or it may be followed by a sudden increase of the 
deafness and tinnitus. 

Diagnosis. — (a) Thickening, contractions, and chalky deposits in 
the drumhead. 

(b) The drumhead often presents a ground-glass appearance. 

(c) Marked negative Rinne with loss of hearing for low tones shows 
middle-ear involvement. 

(d) Adhesive bands may be present, and the Rinne test does not show 
a marked negative result. Labyrinthine involvement probably present. 

(e) High tones are heard better than low ones. In some cases, how- 
ever, there is loss of hearing for high tones, thereby indicating laby- 
rinthine involvement. 

(/) By the use of Siegle's otoscope (Fig. 372) the drumhead may be 
made to move back and forth under alternate suction and pressure. If 
adhesions are present, the drumhead will remain fixed at these points. 

(</) Inflation of the middle ear will cause thin portions of the drum- 
head, when present, to bulge outwarfl like bubbles. Improvement of 
hearing usually lasts while the bubbles remain inflated. The adherent 
parts remain unmoved under inflation. 

(h) Marked movement of the handle of the malleus precludes anky- 
losis of the malleus and incus. Ankylosis of the incus diminishes tlie 
movement of the malleus.. 



ADHESIVE PROCESSES IN THE MIDDLE EAR 697 

Prognosis. — The prognosis will be studied under two headings, namely : 
(1) The more favorable signs, and (2) the unfavorable signs. 

The More Favorable Signs. — (a) Fibrous bands following the secre- 
tive form of catarrh are more favorable than those from the insidious 
type which are more often associated with labyrinthine disease, (b) If 
the case has not progressed to a high degree of deafness the prognosis 
is more favorable, (c) If subjective noises have been but little mani- 
fested, the prognosis is more favorable, (d) Good bone conduction is 
also a favorable sign, (e) Improvement in hearing and tinnitus after 
inflation is a good sign. 

The Unfavorable Signs. — (a) Early deafness. (6) Slight orno increase 
in the hearing distance after inflation of the middle ear. (c) Diminished 
bone conduction, (d) Advanced age. (e) Constitutional ailments. (/) 
Heredity. 

It should be said that complete restoration of hearing is not possible 
in any of the cases, as the changes have been of long duration and are 
retrograde in character. 

Treatment. — This is most conveniently divided into (a) non-surgical 
and (6) surgical treatment. The purpose of treatment should be three- 
fold, namely, to improve the hearing, mitigate the tormenting subjective 
noises, and check the progress of the disease. 

Non-surgical Treatment. — The form of treatment most in vogue among 
physicians in America is inflation of the middle ear, by either the Politzer 
method or through the Eustachian catheter. Politzer claims better 
results by his method than by the use of the catheter. This is probably 
due to the fact that the Eustachian tubes are usually quite patent and 
easily inflated by the bag. Those cases which show improvement after 
the use of the air bag are more favorable for treatment than those which 
show no improvement. The longer the improved hearing continues 
after each inflation the more hopeful is the prognosis. The object of 
middle-ear inflation is to restore the normal air pressure to the cavity of 
the middle ear and to stretch or break down recent adhesions. It is quite 
probable that but little effect of this kind is produced by this procedure, 
except in the early stages while the adhesive bands are slight and fragile. 
The chief use, therefore, of intratympanic inflation is to equalize the air 
pressure, and thus overcome in some measure the pressure upon the 
la})yrinthine fluid and auditory nerve endings. 

Local medical treatment has but little if any curative effect. The medi- 
cated vapors and nebulae, so much extolled in the medical literature a few 
years ago, have no appreciable effect whatever, except such as may be 
explained by the inflation which usually accompanies their use. We may 
say the same in regard to many of the medicines injected through the 
Eustachian tubes, as tlieir use is usually preceded by inflation. 

Numerous injections have been recommended for adliesive processes in 
the middle ear, some of which seem to be followed by good results. Only 
those wliich have provcvl of s]K>cial value will be referred to here. 

The following foi-iniila has been used extensively by Politzer wilh 
favorable results: 



698 THE EAR 

I^ — Sodii bicarb gr. x 

Glycerini V\ viiij 

Aqu» des q. s. 3j — M. 

Ft. sol. 

Sig. — Inject 5 to 8 drops into the middle ear 2 to 3 times per week. 

It acts mildly and does not cause irritation. 

Pilocarpine is another popular remedy, and should be used in a 2 per 
cent, solution, 5 to 6 drops being injected into the middle ear. Perspira- 
tion and salivation usually occurs while the patient is still in the office, 
especially in those cases in which the membrane of the middle ear is still 
boggy and well supplied with bloodvessels. In the dry or trophic type 
these symptoms may not occur. It should not be used in patients with 
weak hearts. 

Delstanche recommended that liquid vaseline be injected into the 
middle ear through a catheter. jVI. A. Goldstein has also reported 
favorable results from its use. It is claimed that it lubricates and softens 
the fibrous tissue, and that the force used in its introduction stretches 
the fibrous bands and liberates the ossicles. To me it appears that the 
only benefit to be derived from its use is obtained by the simultaneous 
inflation of the middle ear. 

Caution. — Whatever method of medication is used, extreme care should 
be exercised lest too great an irritation be produced by the remedy. 
Temporary improvement only follows excessive irritation. The case 
then rapidly passes into a worse condition than before treatment. 

Massage. — The alternate rarefaction and condensation of the air in the 
external acoustic (auditory) meatus moves the drum membrane back and 
forth. As the handle of the malleus is located between the layers of the 
drum membrane, it is also propelled inward and outward with the move- 
ments of the drumhead. If there are firm adhesions binding it down to 
the promontory, it will not perform these excursions unless there is power 
enough in the membrane to tear it loose. This seldom occurs, as the 
adhesions are strong and capable of resisting considerable force. Then, 
too, the drumhead is expansile, and will stretch to the point of bursting 
before the cicatricial adhesions are overcome. Notwithstanding, marked 
improvement occasionally follows the use of pneumatic massage. 

Bing has recommended prolonged rarefaction of the air in the external 
auditory meatus by the use of an olive-tipped instrument inserted into the 
meatus. The tip is perforated and has a valve at its inner extremity. 
The air is withdrawn from the meatus through the rubber tubing, where- 
upon the air pressure closes the valve. In this way rarefaction can be 
maintained for one-half to one hour. He thinks that in some cases this 
is an advantage over simple alternating rarefaction and condensation of 
the air in the meatus. 

Lucae has devised a spring probe with a cup-shaped extremity to fit 
over the short process of the malleus. Pressure is exerted upon the 
short process, and the malleus made to move. This motion is trans- 
mitted to the other ossicles, ankylosis and cicatricial adhesions being 
stretched or broken down. The treatments are very painful, and are, 



ADHESIVE PROCESSES IN THE MIDDLE EAR 699 

therefore, not used to any great extent. If this difficulty could be over- 
come, the use of the probe would prove of great value in the treatment of 
these cases. I would suggest the advisability of administering nitrous 
oxide gas and using the probe during the brief anesthesia. There is little 
danger or inconvenience connected with this anesthetic, and the exigen- 
cies of the case often warrant its use. The injection of a 2 per cent, 
solution of cocaine into the middle ear through the catheter may also be 
used to mitigate the pain. I would advise the use of the probe in suit- 
able cases at intervals of seven to ten days, inflation being practised on 
alternate days. If the element of pain can be eliminated, it is the remedy 
jpar excellence in cases in which the adhesive processes are not too far 
advanced. The hearing is sometimes improved to a remarkable degree, 
and the subjective noises correspondingly diminished. The improve- 
ment is not permanent in a majority of cases, nor is it by any other 
method of treatment. Inflation should also be practised. 

The length of time during which any of the aforesaid treatments should 
be continued varies. It should only be continued while the hearing dis- 
tance continues to increase. This usually ranges between two and six 
weeks. The greatest amount of improvement occurs during the first six 
or eight days. To continue the treatments longer than improvement of the 
hearing distance increases often leads to speedy ill effects. 

As the improvement in hearing is temporary, it becomes necessary 
to give occasional treatments to maintain their beneficial effects. 
Politzer thinks his method of inflation the best adapted for the after- 
treatments. 

Stenosis of the Eustachian tubes may be overcome by inflation if due to 
accumulation of mucus, or by the use of bougies if due to the formation 
of fibrous bands or rings within its lumen. If bougies are used, they should 
be introduced through the Eustachian catheter. In the adult the tube 
is about one and one-half inches long, and the bougie should be 
passed through its entire length. Bougies may be made of whalebone, 
catgut, or celluloid. If for any reason it is desirable to locate the stricture, 
an olive-tipped bougie should be used, whereas to secure its therapeutic 
effect it should be filiform in shape. Medicated bougies (silkworm 
gut) may be used and left in place for twenty or thirty minutes. A 
weak solution of the nitrate of silver is the astringent chiefly used for this 
purpose. 

The introduction of the catheter should be done with extreme caution 
and gentleness, as force may cause it to penetrate the mucosa of the 
tube. This would be unfortunate, as subsequent inflation might cause 
emphysema of the submucous tissues. This accident occasionally 
haj)pens in catheterization of the tubes through abrasions made during 
the manipulation of the catheter. 

Internal medication is of value in those cases sufl'ering from consti- 
tutional diseases. I have seen cases resist all treatment until iron and 
arsenic were administered. Others will improve in hearing when the 
iodide of potash or tonics are given. But even these cases do not entirely 
recover; they only become somewhat improved in hearing and tinnitus. 



700 THE EAR 

I am indebted to Dr. Geo. F. Suker for the following statement of the 
conditions of the ear in which thiosinamine is indicated. In 1S97-9S he 
used it in a number of such, cases, and bases his conclusions upon this 
experience together with the literature concerning its use in other con- 
ditions: 

"The class of cases in which thiosinamine has been found of value 
come under the following heads: 

1. "So-called cases of catarrhal deafness in which there is a diapedesis 
of leukocytes into the meshes of the membrana tympani which ultimately 
cause cicatricial-like thickening. 

2. "Cases of subacute suppurative otitis media with a small perforation 
of the drum. The latter is thickened by infiltrations, but there is no true 
fibrous ankylosis of the ossicles. 

3. "Cases of inflammation of the middle ear, suppurative or otherwise, 
leading to a fibrous ankylosis of the ossicles and with very slight struc- 
tural changes of any kind in the memlwana tympani. 

4. "Cases of deafness, rather a loss in the acuity of hearing, due, as we 
have reasons to suppose, to some fibrous changes in the auditory nerve 
or its endings. 

5. "Cases in which two or more of the above-mentioned conditions are 
present in the ear. 

6. "Cases of suppurative otitis media with extensive loss of drum sub- 
stance and the formation of fibrous bands which impede the free action 
of the ossicles. 

7. "Cases in wdiich there is a transudation of the lymph into the 
substance of the drum, wdiich, instead of being absorbed, remains 
and becomes partly organized, thus causing drum thickening, and, there- 
fore, interferes with the transmission of sound waves. 

"All such cases, if the thiosinamine is persistently given in alternating 
periods of time, will be markedly benefited. It can be administered by 
the mouth or hypodermically. If by the mouth, the dose can be rapidly 
increased until 6 to 10 grains per day are taken. If employed hypo- 
dermically, use a 10 per cent, solution in equal parts of glycerin and 
water. Of this, give 12 to IS mm. three times a week. 

"Thiosinamine acts as a glandular stimulant; at first, for several hours, 
it causes a breaking down of the exudate. Its powers of removing or 
absorbing an exudate is not unlike that of potassium iodide and 
mercury, peptone, pepsin, sodium urate, and allied bodies. 

"In employing the thiosinamine treatment, the hygienic and other 
needed regime must not be overlooked. Give it for periods of six 
to eight weeks and then cease for a week or ten days, after which begin 
again." 

AVhether or not larger experience will support the claims thus clearly 
set forth remains to be demonstrated. Enough evidence is available, 
however, to justify extended trials of it. Its favorable action on keloids 
and lupus is well known. 

Rest is another therapeutic measure of special value in neurasthenic 
cases. I have seen cases make material improvement both in hearing 



ADHESIVE PROCESSES IN THE MIDDLE EAR 



701 



and in the severity of the subjective noises under this mode of treatment. 
J. A. Stucky reports good results following rest in bed, with massage of 
the body. 

Dundas Grant recommended vibratory massage of the spinal column 
in these cases. He did not offer any satisfactory explanation of the 
therapeutic action of vibratory massage, but only reports as to its favor- 
able action. More extended observations by Dr. Grant, the author, 
and others has shown the results to be slight and uncertain. 

Surgical Treatment. — Operations on the drumhead for the relief of deaf- 
ness have been done for more than a century. Himly and Astley Cooper, 




Severing an adhesion of the membrana tympani to the promontory. A small trianKular flap 
is made in the drumhead and the right-angle knife introduced through the opening thus made 
and the adhesive band severed. 



in 1795, removed portions of the drumhead and strongly recommended 
the procedure as a means of admitting sound waves to the labyrinth 
and of relieving the increased tension of the ossicular chain. Others soon 
followed in their wake, all to meet with ultimate disappointment, as the 
relief was only temporary. It was found impossible to keep the wound 
open for any length of time. Later vulcanite and metal eyelets were 
used with unsatisfactory results. All efforts to maintain the opening in 
the membrana tym[)ani (drumliead) have failed. The (Hfhculty has been 
to secure the epiderniization of the edges of the wounded membrane. 
The author would suggest the use of the skin graft on the margin of the 
perforation, after the Thiersch method. 



702 '^^J^ EAR 

Malherbe recommends lifting the auricle forward, as in the mastoid 
operation and the removal of the posterior wall of the meatus external 
to the annulus tympanicus. He then establishes communication be- 
tween the middle ear and the meatus via antrum and the aditus ad 
antrum. He maintains the opening by inserting a celluloid or gold 
tube through the opening in the wall of the meatus. He only recom- 
mends this procedure in cases of moderate severity. 

Section of the posterior fold of the drumhead (Fig. 361) was first 
suggested by Politzer in 1871, who says: ''It is advisable in all cases 
where the objective signs of an abnormal inward curvature of the mem- 
brana tympani are present, where the inferior extremity of the handle of 
the malleus is, therefore, abnormally inward, and the short process of 
the malleus and the posterior fold of the membrane extending from it 
project strongly toward the external meatus. If these changes are com- 
bined with a disturbance of hearing of a high degree and loud subjec- 
tive noises, which cannot be materially improved by the local methods of 
treatment, an experimental section of the posterior fold is justifiable in 
such cases." 

The operation is simple and consists of a section of the fold just pos- 
terior to the short process of the malleus or midway between it and the 
peripheral extremity of the fold. The knife should not penetrate deep 
enough to sever the chorda tympani nerve in its passage between the 
malleus and incus. 

The handle of the malleus should immediately drop downward and 
forward as the tension is relieved. The tinnitus is usually most relieved, 
although in some cases there is also an improvement in hearing. The 
benefits last only a few weeks or months in most cases. 

Adhesion of the drumhead to the promontory may be overcome by 
making a small triangular opening in the drumhead and introducing a 
right-angle knife through it. The adhesion is then severed, as shown 
in Fig. 374. 



CHAPTEK XLIL 

HYPEROSTOSIS OF THE BONY CAPSULE OF THE LABYRINTH. / 

Synonyms. — Spongifying of the bony capsule of the labyrinth; oto- 
sclerosis; otitis media insidiosa; hyperplasia of the bony capsule of 
the labyrinth; capsulitis labyrinthii. 

According to Henry J. Hartz, this disease is ^'fundamentally an hyper- 
plasia of the bony capsule of the labyrinth; the hyperplasia is a trans- 
formation of cartilage into bone, i. e., metaplasia, accompanied by the 
formation of an outgrowth of bone, i. e., hyperostosis." 

Etiology. — The dense bone of the osseous capsule of the labyrinth 
contains cartilaginous cells, hence it is the area of election for the trans- 
formation of the cartilage into bone. The ossicles also have cartilage 
cells in them, and may be the seat of this disease. The distribution of the 
cartilage cells is most constant in the posterior half of the margin of the 
oval window (fenestra of the vestibule), hence this is the most frequent 
site of the morbid process. They are also found in the capsule of the 
semicircular canals and the upper and lower walls of the cochlea. Any 
or all of these points may be affected and give rise to symptoms peculiar 
to the physiological bearings of the various structures. That is, the 
hyperostosis may be limited to the ossicles, the oval window, the cochlea, 
or to the semicircular canals, or it may involve two or more of them 
at once. 

In addition to the predisposition of the cartilaginous area to undergo 
metaplastic changes, there are certain extraneous or constitutional 
diatheses which act as exciting causes. Syphilis, scrofula, acute rheu- 
matism, gout, tonsillitis, inflamed processes of the ears, and exposure to 
the inclemencies of the weather have been ascribed as initiative influences 
in the disease. Personally, I do not understand how the inflammatory 
diseases of the tonsils, adenoids, and middle ear can have any relation- 
ship to the metaplastic changes in the capsule of the labyrinth. The 
etiology is still obscure. 

Age exerts a positive influence upon the development of the disease. 
It usually begins between the eighteenth and the fortieth years of life. 
Heredity has been noted as a rather common factor in the etiology, many 
cases giving a history of other members of the family having had the 
disease. In a noted American literary family several members were 
affected by it. The majority of the cases occur in young women. Sexual 
intercourse and parturition aggravate the symptoms, probably on account 
of the increased hy[)eremia produced by these acts. The marriage of 
women aflected by this disease should, therefore, be carefully considered 
before being consummated. 



704 THE EAR 

Pathology. — ^Accordino; to Denker, the osseous changes may be divided 
into two stages, the first of which consists in an active prohferation of all 
the cellular elements within the bone. New vascular and cellular tissue 
is formed in the narrow spaces and in the Haversian canals. Among the 
newformed bone cells may be found giant cells, under the influence of 
which the basement of the bone substance is principally absorbed. 
Hollow spaces are formed, and areas of erosion gradually undermine 
the originally compact bone, which becomes traversed by irregular 
and abnormal channels. With the absorptive process there is the 
formation and apposition of new bone, which is unlike the original, it 
being more voluminous and porous. The second stage is ushered in when 
the progressive changes cease and when the new bone assumes a lamellar 
structure. Then the abnormally large and thick bone corpuscles are 
found concentrically arranged, and the nucleus of these later undergoes 
atrophy. The vascular system is likewise gradually altered by the forma- 
tion of connective tissue, in which at times may be found fat cells. The 
Haversian canals and spaces have been changed in structure by this 
resorptive and appositional process, and all the cartilaginous elements" 
have been metamorphosed into osseous tissue, as it cannot be found in 
the new -growth. Thus the process constitutes not only an hyperplasia 
and hyperostosis, but also a metaplasia. 

The new structure differs from the normal by its affinity and greater 
absorptive power for carmine stains, which fact is utilized in the differ- 
ential diagnosis. The microscopic evidence of this new formation are 
the osteophytes, situated usually near the stapes articulation. Frequently 
the stapes is partially absorbed by penetrating bloodvessels and replaced 
by osseous formations. Sometimes a dislocation of the stapes is produced 
by an encroachment of the osteophytes. The functions of the oval and 
round windows may also be seriously interfered with by the hyperostosis 
producing partial or complete occlusion. When the process invades 
the base of the cochlea, the patency of the Eustachian tube is threatened. 
Its lumen is narrowed by thickening of the periosteum, as has been 
demonstrated by the microscope. Owning to the great vascularity attend- 
ing it, especially the first stage of the process, it is probable that the 
distressing tinnitus of progressive deafness may have its origin in the 
increased capillary circulation. 

The structural alteration consequent upon an invasion of this bone 
formation into the cochlea and the semicircular canals may cause a 
change in the pressure and the density of the labyrinthine fluid. The 
mechanical and physical qualities of the endolymph and perilymph 
may be so altered as to interfere with the nutrition of the parts and 
induce disease. The detonating sounds heard by some patients and 
the symptom complex of Meniere may be ascribed to a perforation of 
the septum dividing the endolymph and perilymph systems. 

While the histological alterations were found to be identical by dif- 
ferent authorities, yet their designation of the bone hyperplasia differs 
and new synonymous terms are consequently introduced. Politzer 
defines it as capsulitis labyrinthii or otosclerosis. Siebenmann, noting 



HYPEROSTOSIS OF THE BONY CAPSULE OF THE LABYRINTH 705 

the resemblance to sponge because of the rarefied spaces and porous 
structures, designated the new formation as spongification. Katz com- 
pares the process to Volkmann's osteitis vascularis chronica. From 
personal observations of different specimens the osseous change appears 
to be identical with the rarefying osteitis of our text-books. 

Sjrmptoms and Diagnosis. — The symptoms, while more or less con- 
stant, vary with the anatomical structures involved. If only the ossicles 
are affected, the ankylosis of the stapes may be partial or complete; if the 
posterior bony margin of the oval window is the seat of the changes, 
the ankylosis may be complete and the stirrup pulled posteriorly by the 
stapedius muscle; if the cochlea is involved, the signs of nervous deafness 
are present, i. e., diminished bone conduction and the loss of hearing for 
the upper tone limit; if the process is in the semicircular canals, giddiness 
and nausea may be present. In mixed cases there may be a combination 
of these symptoms. 

In the cases as commonly recognized in practice the disease is char- 
acterized by the signs of middle-ear disease without the objective appear- 
ances of it. That is, there is (a) loss of the lower tone limit, (b) a nega- 
tive Rinne, and (c) an increased duration of hearing by bone conduction, 
the findings in middle-ear disease. Upon inspection of the membrana 
tympani its appearance is normal, or is so slightly changed that it cannot 
account for the marked degree of deafness present. 

==^When the hyperostosis is located exclusively in the ossicles, the anky- 
losis may be partial or complete, and the symptoms are those of ordinary 
middle-ear disease, except the membrana tympani is normal in appear- 
ance and the Eustachian tubes are open. 

When the hyperostosis is limited to the cochlea, the usual signs of ner- 
vous deafness, loss of hearing for the upper tone limit, positive Rinne, and 
shortened and diminished bone conduction are present. 

When both the oval window and the cochlea are involved, it is prac- 
tically impossible to make a diagnosis. This is also true when the oval 
window is affected by hyperostosis (spongification) and the middle ear 
is simultaneously diseased. Tinnitus is present in nearly all cases, 
and is sometimes very pronounced. 

Summary of Symptoms. — ^As the spongifying or hyperostosis affects 
various parts of the ear structures, the symptoms vary accordingly. 

The following classification includes the chief clinical characteristics 
of each subdivision : 

Hyperostosis about the Oval Window (Fenestra of Vestibule). — 1. Loss 
of hearing for one-half to one and a half octaves of the lower tone limit 
in one or both ears. 

2. Negative Rinne in varying degree. 

3. Prolongation of hearing by bone conduction for fork A of the 
Edlemann-Bczold set of forks. 

4. Hyperemia appearing as a yellowish-red glow of the promontory, 
showing through an otherwise normal appearing membrana tympani. 
The handle of the malleus may be foreshortened, but is not rotated. 

5. Patency of tlie Eustachian tubes. 
45 



70n THE EAR 

Hyperostosis of the Stapes. — The same as the preceding except in a 
less flefjree. 

Hyperostosis of the Cochlea. — 1. Loss of hearing for the upper tone 
Hmit, and slightly for the lower tone limit. 

2. Positive Rinne. 

3. Shortened duration of hearing by bone conduction for fork A. 

4. Hyperemia of promontory showing through an otherwise normal 
membrana tyrapani. 

5. Patency of Eustachian tubes. 

Hyperostosis of the Semicircular Canals. — 1. Giddiness or dizziness 
at times. 

2. Nausea may or may not be present. 

3. Perhaps slight deafness. 

4. Membrana tympani and Eustachian tu])es normal. 
Hyperostosis around Oval Window Combined with Catarrhal Otitis Media 

or Other Middle-ear Disease. — 1. Loss of hearing for one-half to two 
octaves of the lower tone limit. 

2. Negative Rinne in varying degree. 

3. Prolonged hearing by bone conduction for fork A. 

4. Retraction of the membrana tympani. 

5. Foreshortening and rotation of the malleus. 

6. Eustachian tube obstructed. 

A positive diagnosis of spongifying in a case with the above symptom 
complex is impossible. 

Prognosis. — The cure of the disease appears to be impossible. In a few 
cases slight or temporary improvement follows treatment. In the early 
stage of the disease certain medicinal, mechanical, and surgical proced- 
ures afford relief. In the later stages all remedial measures fail. 

Treatment. — ^Medicinal. — Small doses of phosphorus, gr. ^75-0, 
three times daily, for six months of the year, has given the best results. 
It acts best in the early stages during the active proliferation of the 
cellular elements within the bone, when new vascular tissue is being 
formed in the narrow spaces and Haversian canals, and absorptive pro- 
cesses and apposition of new^ bone is in progress. 

Thyroid extract has likewise occasionally given good results under the 
same conditions. 

Iodine, in the form of the iodide of potash, and mercury have been given 
by Politzer with good results when the diagnosis was made early on 
account of other members of the family having had the disease. That 
is, the appearance of the disease was carefully watched for, because its 
coming was expected on account of the hereditary influence known to 
be present. When a father or mother is known to have the disease, 
they should be warned that their children are liable to the same trouble, 
and that they should be periodically examined after puberty for its 
earliest expression. In this way there is some hope of modifying its 
progress by the administration of phosphorus, iodide of potash, or 
thyroid extract, and by the correction of inflammatory disease of the 
tonsils and adenoids, and of rheumatic, gouty, and scrofulous diseases. 



HYPEROSTOSIS OF THE BONY CAPSULE OF THE LABYRINTH 707 

Thyroidectin in five-grain capsules may be given three times a day. 
Depletion of the vessels of the head may be produced by the adminis- 
tration of cathartics and by hot foot and sitz baths. 

An early diagnosis is positively necessary, and heredity should give 
warning of the impending disorder. 

Mechanical. — Pneumomassage with the Delstanche rarefacteur (Fig. 
14) may be used to mobilize the ossicles when they are not excessively 
ankylosed (Hartz). 

Clarence Blake has called attention to the fact that in practising 
pneumomassage gentleness should be observed in its application, as, 
otherwise, the whole ossicular chain may be dislocated and irreparable 
damage done. He also calls attention to the fact that the posterior seg- 
ment of the membrana tympani may become relaxed by excessive mas- 
sage. Indeed, great damage may be done by any treatment addressed 
to the Eustachian tubes and middle ear. Aurophones are also damaging 
to this disease. The massage should therefore be gently administered, 
preferably with a hand pump, for one to two minutes, two or three times 
a week, for two months. After a rest of two months the massage may be 
tried again. Further massage may be given at the discretion of the 
aurist. As soon as the nature of the disease is known the patient should 
be advised to begin a systematic course in lip-reading. 

Surgical. — Stapedectomy has been tried with almost universal failure. 
Jack has performed the operation a number of times with but one or two 
permanent improvements. In some cases stapedectomy is followed by 
the formation of scar tissue over the oval window, thus rendering the 
hearing worse than before the operation. 



CHAPTER XLIII. 

ACUTE AND CHRONIC SUPPURATIVE OTITIS MEDIA. 
CHOLESTEATOMA. 

ACUTE SUPPURATIVE OTITIS MEDIA. 

This type of inflammation of the middle ear is characterized by- 
marked hyperemia of the mucous membrane of the middle ear, includ- 
ing the inner wall of the drumhead. This may be followed by pain and 
perforation of the drumhead, through which the pus discharges into 
the external auditory meatus. 

Etiology. — The exciting cause of this disease is the presence of 
pathogenic microorganisms in the middle ear, as already described under 
Acute Catarrhal Otitis Media; indeed, the catarrhal inflammation often 
assumes the suppurative type after a few days. In many cases the 
inflammation remains catarrhal in type until the drumhead is per- 
forated, the microorganisms thus receiving the required environment 
to promote their rapid propagation, though spontaneous rupture some- 
times promotes a rapid reparative process, due to good drainage and 
the increased reactions of inflammation. (See Chapter VI.) The per- 
foration may occur either spontaneously or by surgical intervention. 
Incision of the membrana tympani is not contraindicated, as, if it is done 
under aseptic conditions, the danger of increased infection is reduced to 
the minimum; indeed, the reactions of inflammation are promoted, and 
the infection is thus overcome instead of being increased. Some cases 
are undoubtedly suppurative in type from the beginning, the inflamma- 
tion, temperature, and pain being more pronounced than in the simple 
catarrhal inflammation. 

Arthur B. Duel arrives at the following conclusions in reference to the 
relation of the infectious fevers to acute suppurative otitis media, his 
conclusions being based upon a study of 6000 cases of scarlet fever, 
measles, and diphtheria in the Willard Parker Hospital : 

Acute purulent otitis developed in about 20 per cent, of the scarlet 
fever cases, in about 10 per cent, of the diphtheria cases, and in about 
5 per cent, of the cases of measles. There were 26 mastoid cases, 2 in 
measles, 2 in scarlet fever, and about 20 in combined scarlet fever and 
diphtheria. Two were complicated with thrombosis of the lateral 
sinus. 

Time of appearance: In scarlet fever the ear complications occurred 
the second or third week; in diphtheria, during the acute symptoms; in 
measles, during the acute stage, fever still being present. 

In scarlet fever there was usually much greater destruction of tissue 



ACUTE SUPPURATIVE OTITIS MEDIA 709 

than in diphtheria or measles. A combination of two or more of the 
infectious diseases increased the danger, nearly one-half of such cases 
developing acute suppurative otitis media, and mastoiditis was a fre- 
quent sequela. 

The Rivinian segment as an etiological factor: In children under 
five years of age Duel found postauricular swelling present most con- 
stantly, which, he thinks, was due to the escape of pus through the 
unclosed Rivinian segment. Between the ages of five and ten the post- 
auricular swelling was due to perforation of the thin mastoid cortex. 
In older children mastoid swelling was rare, except in those cases in 
which the external meatus was greatly inflamed. In all cases there was 
sagging of the postsuperior wall of the meatus near the drumhead. 

The jpredisposing causes are colds, exposure, chronic rhinitis, chronic 
and acute epipharyngitis, adenoids, enlarged or inflamed tonsils, syph- 
ilis, tuberculosis, and other constitutional diseases. The acute exan- 
thematous fevers, as scarlet fever, measles, diphtheria, whooping-cough, 
and influenza, are also responsible for many cases. The use of the 
nasal douche sometimes causes the disease. I formerly used the nasal 
douche quite frequently in my office practice, but abandoned it after 
seeing two or three cases of acute suppurative inflammation resulting 
directly from it. Cold injections into the meatus, bathing, diving, and 
snuflSng cold fluids into the nose also act as predisposing causes. 

Age has a direct influence, a large majority of the cases being in chil- 
dren. The damp, unsettled weather of the autumn and spring also 
favors its occurrence. 

Those cases occurring independently of any other disease are usually 
unilateral, while those occurring in connection with scarlet fever, diph- 
theria, measles, epipharyngitis, and adenoids are usually bilateral. 

Finally, it may be stated that all conditions which lower the resistance 
of the tissues of the middle ear predispose to infectious inflammation. 
The exciting causes are the pathogenic microorganisms. The various 
constitutional diseases and the local diseases of the fauces, nose, and 
epipharynx produce lowered cell resistance, and predispose to the in- 
fection. 

The indications, in view of the foregoing facts, are to remove the pre- 
disposing causes and increase the reaction of inflammation, in order to 
increase the resistance of the tissues and to destroy the bacteria and 
their toxins. (See Inflammation, and the Methods of Promoting the 
Reaction of Inflammation, Chapter VI and VII.) 

Symptoms. — The symptoms may be grouped under pain, tempera- 
ture, the appearance of the membrana tympani, the character of the 
secretions, the subjective noises, and the disturbances of hearing. 

Pain. — The pain is sometimes preceded by a feeling of heaviness in 
the ear, or by a severe headache. The pain may be piercing, tearing, 
boring, or throbbing in character, and is more severe in children than in 
adults. It is continuous, but it becomes less severe toward morning, 
when the patient falls into a sound sleep. Photoi)ho})ia, edema of the 
eyelids, and conjunctivitis occasionally complicate severe inflammations 



710 I'HE EAR 

prior to the time of perforation of the driiinhead. Facial paralysis 
and trii;(nninal neuralgia occasionally complicate the disease. 

Temperature. — The temperature at the onset is elevated from 1° to 3°, 
and is sometimes preceded by a slight chill, or creepy sensations, 
and, occasionally, in very young children, by convulsions. After the 
suppurative process is well established, and drainage is taking place 
through the perforation in the drumhead, the temperature subsides to 
about 1° above normal. 

The Membrana Tympani. — In the early stages the membrana tympani 
presents the appearances found in acute catarrhal otitis media. It is 
scarlet red, ecchymotic, swollen, and more or less bulging. The handle 
of the malleus is obscured by the swollen drumhead. In the post- 
superior quadrant of the membrana tympani a blister is sometimes pres- 
ent, giving a pearly lustre to this area. If the case is seen quite early, 
the round spots due to the bubbles of air in the viscid mucus may be 
seen through the still transparent drumhead. In the influenzal cases a 
hemorrhagic bleb often completely covers the drumhead. After a day 
or two the posterior half of the drumhead becomes covered by dead, 
cracked epithelium, beneath which there is a serous infiltration. Politzer 
was the first to show that the light reflexes on the bulging portions of the 
posterior segment of the drumhead sometimes pulsate. The yellow 
purulent secretion behind the membrana tympani does not show as often 
as one might expect, on account of the swollen and reddened condition 
of the membrane. Occasionally, however, a greenish-yellow bulging spot 
may be seen, and when it appears, perforation is imminent. 

In diabetic patients, and occasionally in others, small interlamellar 
abscesses form in the posterior segment of the membrana tympani, or 
near the umbo. They are of the size of a millet-seed, and rupture early 
in the course of the disease. 

The External Auditory Meatus. — The osseous portion of the meatus is 
almost always hyperemic, and is sometimes infiltrated, and more or less 
covered with blisters. The cartilaginous portion of the meatus is in- 
jected and painful in severe inflammations, the infection taking place 
through the numerous anastomoses of the capillary bloodvessels be- 
tween the mucous membrane of the tympanic cavity and the skin of the 
meatus. The swelling and redness, or the so-called "sagging" of the 
postsuperior portion of the osseous meatus, near the membrana tym- 
pani (Fig. 375), occurs in those cases in which there is a marked 
suppurative process in the Kirschner mastoid cells. When it occurs 
it is usually a positive indication for the mastoid operation. 

Perforation, — Perforation takes place at the seat of one of the inter- 
lamellar abscesses, or at the most bulging portion of the drumhead, 
generally in the anterior half, although it may occur in the posterior 
segment. The size and shape of the perforation varies, usually being 
an ill-defined area with triangular edges, while in others it appears as a 
small dark round spot, with a pulsating drop of mucus covering it. In 
still other cases the opening cannot be located. Inflation sometimes 
enables the observer to distinguish its edges. The same is true when 



ACUTE SUPPURATIVE OTITIS MEDIA 



711 



the air is rarefied in the external canal with Siegle's otoscope (Fig. 369). 
The perforation is usually single, although in tuberculous patients it is 
multiple and near the margin of the drumhead (Fig. 377). In influ- 
enzal otitis the perforation often occurs on the apex of a nipple-shaped 
elevation. A nipple-shaped perforation is, therefore, significant of 
serious mastoid disease. Even under favorable conditions, the nipple- 
shaped perforation persists for quite a time. In those cases occurring 
independent of one of the infectious diseases the perforation rarely ex- 
ceeds the size of a millet-seed, whereas in cases secondary to the infec- 
tious fevers the perforation may be so large as to destroy the entire 
membrana tympani. The membrana flaccida (Shrapnell's membrane) 
is rarely perforated in acute suppurative otitis media. 

Secretions. — ^The secretions may be serous, seromucous, serosan- 
guineous, seropurulent, mucopurulent, or mucohemorrhagic. If it is 
purulent, it often runs a more favorable course than the mucopurulent 
type. The quantity of pus, serum, 

and mucus varies greatly at difi'er- Fig. 375 

ent times, and one form of secretion 
may alternate with another. In neph- 
ritic, cachectic, leukemic, hemophiliac, 
and traumatic cases the hemorrhagic 
secretion is usually present. 

Subjective Noises. — Pulsating 
noises sometimes occur in acute sup- 
purative otitis media, although they 
are not always present. They are 
due to the increased pressure within 
the cavum tympani from the hyper- 
emia and excess of secretion. The 
la})yrinth is also hj'peremic and 
somewhat infiltrated, the noises being 
there1)y augmented. Autophony is 
sometimes present. 

The Hearing. — The hearing is impaired somewhat in proportion to the 
amount of congestion and secretion present. As the disease progresses, 
and the membrane becomes more congested, and the cavity filled with 
the secretion, the deafness, which at first was slight, becomes quite pro- 
nounced. In scarlatinal and diphtheritic infections involving tlie laby- 
rinth the deafness may be profound and hearing for high tones lost. 

Hearing by ])one conduction for the watch, tuning-fork, and acou- 
meter remains intact, excej)t in those cases wherein the labyrinth is 
involved. In the We])er test tlie sound is lateralized to the diseased ear, 
except in the aforesaid labyrinth cases, in wliicli it is lateralized to the 
sound ear. 

Course. — Taking the perforation of the drumhead as one of the 
early milestones in the progress of the disease, we may subdivide it into 
three classes, namely: (a) Those cases running a very rapid and de- 
structive course, wherein the drumheiid is perforated widiiii (he first 




Bulging or sagging of the posterior superior 
wall of the meatus; an imperative indication 
for the mastoid opei-ation. 



712 THE EAR 

one or two days; (h) those cases wherein perforation occurs on the 
third or fourth day (primary suppurative otitis media); (c) and the 
more chronic type, in which perforation occurs withm the second or 
third week of tlie disease. 

Perforation usually ameliorates the sjTuptoms, especially the pain 
due to pressine. Improvement does not always follow, however, 
as the mastoid antrum and cells may also contain pent-up secretions, 
and thus give rise to the pain, in spite of the lowered tension within the 
tympanic cavity. The fever, headache, and subjective noises are also 
abated when perforation and drainage into the meatus take place. 

After a variable time the discharge ceases and the perforation closes. 
In the cases occurring independently of the infectious fevers, the per- 
foration often closes in from one to three w^eks, or it may not close in 
as many months. In those cases due to the infectious fevers and to 
influenza (nipple-shaped perforation), the perforation only closes after a 
protracted period. 

I have seen a fatal type of mastoiditis develop seven years after an 
attack of mild scarlet fever. In one case, seven years after the scar- 
latinal infection, cavernous sinus thrombosis complicating mastoiditis, 
occurred, and was speedily followed by death. In another case, one 
year after a very mild attack of measles, suppurative labyrinthitis de- 
veloped very suddenly, deafness being almost complete. Pachymenin- 
gitis, followed by death four days later, termmated the case. I am 
skeptical in reference to the safety of those patients whose ears become 
infected during the course of the exanthematous fevers. A latent or 
concealed inflammation so often persists, and after a lapse of a few 
years becomes active and destructive to a marked degree. I there- 
fore emphasize the wisdom of giving a guarded prognosis in otitis media 
secondary to the eruptive fevers. In the primary t}^e the prognosis in 
this respect is much more favorable. 

I recognize another t)^e of otitis as having dangerous tendencies, 
namely, those cases rimning an irregular or intermittent course. The 
discharge ceases, and then, after a variable interval, reappears. Pain 
also occurs at irregular intervals. In other words, the acute type be- 
comes chronic and somewhat latent in character. Necrosis of the bony 
tissue takes place, and mastoiditis, complicated with sinus thrombosis, 
brain abscess, or meningitis, occurs. 

Terminations and Sequelae.— This phase of the subject is of great 
importance, on account of the apparent harmlessness of the disease m 
many cases, whereas it is in reality a most grave and destructive one. 
It is not so much the disease that is to be feared as the sequelae. The 
terminations and sequelse should engage the thoughtful consideration 
of the attending physician quite as much as the primary otitis. For 
convenience of discussion, Politzer's classification of the terminations 
will be followed : 

(a) Cure. — That many cases terminate in a positive cure, no vestige 
of the disease remaining, cannot be questioned. That many are pro- 
nounced "cured" when in reality a serious sequela is left as a heritage. 



ACUTE SUPPURATIVE OTITIS MEDIA 713 

is also unquestioned. A careful analysis of the case, its etiology, course, 
etc., should be considered in arriving at a correct conclusion as to whether 
or not it is "cured." What, then, are the points that should be consid- 
ered in arriving at a conclusion as to whether the case is "cured"? In 
the first place, if the case is primary, or independent of a preceding 
infectious fever, and has run a mild and rapid course, and if there are 
no demonstrable ear lesions, it is safe to pronounce the case probably 
cured. Such an opinion should, however, be based upon accurate and 
intelligent observations. I have seen many cases pronounced cured in 
which subsequent results demonstrated the opinion to have been erroneous. 
(6) Catarrhal. — A catarrhal termination is not attended by immediate 
serious consequences, but it may in time produce pronounced im- 
pau-ment of hearing. The perforation may be completely closed by 
cicatricial tissue and a seromucous secretion, with slowly increasing 
deafness and tinnitus as the chief symptoms. 

(c) Adhesive Processes. — ^This form of termination is not rare, but, on 
the contrary, is comparatively common. The thick mucoid secretion 
or exudate becomes organized, the adhesive bands binding the ossicles to 
each other or to the walls of the tympanic cavity. The drumhead may 
also be involved by adhesions to the inner tympanic wall, drawing in 
ridges and folds toward the wall from which the adhesive bands spring. 
The deafness and tinnitus are usually progressive, although they may 
increase by bounds. In the earlier stages, bone conduction is increased. 
Rinne (see Functional Tests of Hearing) being negative, while in the 
more advanced stages Rinne is positive. The positive Rinne in the 
later stage is accounted for by the extension of the sclerotic process to 
the labyrinth. 

(d) Permanent Deafness. — ^Permanent deafness is usually a result of 
tlie secondary infection from scarlet fever, measles, diphtheria, etc., the 
membrana tympani and ossicles being partially or entirely destroyed. 
I have seen cases in which the drumhead and ossicles were entirely 
destroyed, the inner wall (promontory) of the tympanic cavity being 
plainly visible, in which the hearing was remarkably acute. The chief 
loss of function seemed to be an inability to locate the direction of sound 
or speech. After once graspuig the fact that they were being addressed, 
these cases seemingly hear with almost normal acuteness. Another 
cause of permanent, and often very pronounced, deafness is the pano- 
titis of Politzer, wherein the whole auditory apparatus is involved in the 
infective process. In these cases there is caries of the bone separating 
tlie tympanic cavity from the labyrinth (promontory), or tliere is a 
perforation of tlie windows leading to the la})yrint]i. This condition is 
usually sccf)ndary to the infections fevers. 

(r) Mastoiditis. — While mastoiditis nearly always complicates middle- 
ear infection, it is not always severe enough to cause serious symptoms. 
In some cases, however, notably tliose due to the infectious fevers, in- 
fluenza, and typhoid fever, the mastoid involvement often becomes the 
chief problem in the management of the case. In mastoiditis having 
its origin in influenza the abscess is usually circumscribed, and is 



714 THE EAR 

located in the mastoid process, the tympanic cavity containing no pus. 
In cliihh-en the mastoid process is often perforated through the external 
plate, thus giving rise to a subperiosteal abscess. 

ij) Loss of Mucous Membrane, Ossicles, and Infection of the Lab3n:inth. 
— Lal)yrinthitis, while similar in some respects to the condition de- 
scribed under {d) Permanent Deafness, is ditt'erent in regard to the viru- 
lency of the infection. It is found following mild infectious fevers, 
typhoid fever, and tuberculosis. The tympanic cavity is denuded of 
mucous membrane, and the ossicles are necrosed. A probe introduced 
into the cavity through the external meatus shows bare, comparatively 
smooth bony walls. The labyrinth may be exposed by necrosis of the 
promontory or inner wall of the middle ear. The hearing in these cases 
may not be as profoundly affected as in (<:/), though wiien the labyrinth 
is involved the deafness is usually profound. 

[g) Chronic Suppuration. — This seciuela is not so much to be dreaded 
as the more latent form, in which there seems to be a cure, w4ien necrosis 
is probably steadily progressing. In the open frank chronic suppura- 
tion the physician and patient are not so readily deceived, but recognize 
the possible danger still attending the further progress of the disease. 

{h) Death. — A fatal issue may result early in the disease from menin- 
gitis, sinus thrombosis, septicemia, or brain abscess. The infection 
may reach the meninges through the labyrinth, the tegmen antri or 
tympani, or through one of the open sutures of the temporal bone in 
infants and children. 

Diagnosis. — The diagnosis of acute suppurative otitis media is 
neither easy nor simple. The difference between it and acute catarrhal 
otitis media is often so slight in the early stage of the suppurative type 
that only a careful and intelligent examination will enable the surgeon 
to make a correct diagnosis. 

(a) Pain. — In suppurative otitis media the pain previous to perfo- 
ration is very intense and boring in character, especially in children, 
whereas in adults it is not so severe. 

(6) Temperature. — The temperature ranges from 1° to 3°, or even 
more, above normal in children. It does not run so high in adults. 
In catarrhal otitis media the temperature does not usually exceed 1° or 2° 
above normal. 

(c) Appearance of the Drumhead. — In suppurative otitis media before 
perforation it is quite similar in appearance to that of catarrhal otitis 
media. After perforation a dark spot is seen in a few cases, wdiile in 
others the perforation is not visible. A pulsating droplet of mucus or 
pus is, however, significant of perforation. If the drumhead is destroyed 
the red promontory may be seen when the pus is cleared away. 

{d) The Probe. — ^The probe may be used to differentiate between a 
reddened promontory w^all and a reddened drumhead. The promon- 
tory is firm and unyielding, while the drumhead is resilient. With the 
probe a flake of mucus or pus may be brushed away, and thus show 
whether a perforation or intact membrane is present. Necrosis of the 
inner wall of the tympanic cavity may be demonstrated with the probe. 



ACUTE SUPPURATIVE OTITIS MEDIA 715 

(e) Inflation. — Inflation of the middle ear and the simultaneous use 
of the diagnostic tube will produce a whistling tympanic murmur when 
perforation is present, or a soft blowing tympanic murmur when the 
drumhead is intact. Inflation should be practised with caution in acute 
cases, as the infectious material may thus be forced into the deeper re- 
cesses of the tympanic and mastoid cavities. If, during inflation, the 
distal end of the diagnostic tube is dropped into a basin of water, bub- 
bles of air may be seen to rise if perforation is present. A manometric 
tube partly filled with water and inserted into the external meatus dur- 
ing inflation will cause the column of water to rise in the distal arm of 
the U-shaped tube during inflation if a perforation is present. 

(/) Compression of Air in the Meatus. — Compression of the air in the 
external canal wdll force air through the perforation into the middle ear. 
The sound may be heard by inserting one end of the diagnostic tube into 
the nose of the patient (one nostril being closed), the other end being 
placed in the external auditory meatus of the observer. 

Prognosis. — ^The prognosis has already been quite fully considered 
under Terminations and Sequelee. 

Treatment. — ^The treatment wdll be considered in connection with 
the subject of middle-ear suppurations in general. A brief resume will, 
however, be given in this connection. 

(a) Complete asepsis or cleanliness and drainage should be striven 
for, to prevent the otorrhea becommg chronic. To fail in this regard 
subjects the patient's life to great hazard. If thorough asepsis is 
maintained, a secondary staphylococcus infection will be prevented. 
Staphylococcus infection means chronicity. Do not allow it to occur. 

(b) In the early stage, before perforation occurs, a 12 per cent, solu- 
tion of carbolic acid in glycerin (A. H. Andrews) should be dropped 
into the meatus. It is also a valuable remedy after perforation has 
occurred, as it is hygroscopic, reduces the edema of the mucous mem- 
brane, and thus establishes a more rapid flow of blood through the 
tissues. The resistance of the tissues is thus raised and the infection 
checked. 

(c) Early incision of the drumhead should be practised at its most 
bulging portion. The incision should be free and curved to allow of 
good drainage. Simple puncture, the so-called paracentesis, is never 
indicated. It is an obsolete procedure. Drainage is the object sought 
for, hence use the lance with a free hand. Incision also promotes the 
reaction of inflammation, and thus favors a speedy resolution (Fig. 376). 

id) If the secretions are thick and tenacious, the syringe may 
be used to remove tliem. A sterile alkaline solution should always 
be used for this purjwse, as it thins the secretion and facilitates its 
removal. 

(e) An acjueous solution of the peroxide of hydrogen or hydrozone 
may also be used to l)reak down the secretions, after whicli they are 
more readily wiped away witli a cotton-wound probe. 

(/) The cotton-woinid ])robe should be used gently, but repeatedly, at 
each sitting, to Avipe away all tlie secretion present. In my experience 




716 THE EAR 

this is the most eft'ectual method of removing the secretion in those cases 
in which the perforation is of large size. 

{g) Inflation of the middle ear may be practised with caution after 
the pain and other acute symptoms have subsided. 

{k) A safer procedure is to use suction with Siegle's otoscope in the 
external auditory canal. 

(i) Constitutional treatment: Calomel may be given in yV grain 
doses three to ten times a day. For the relief of the pain, 1 grain of 

codeine, or 3 to 6 grains of phenacetin 
may be given. The epipharynx should 
be frequently gargled after the von 
Troltsch-Swain method. 

{j) Six weeks of daily inspection 
and appropriate treatment will, in 
most cases, result in a complete cure. 
Less faithful and intelligent attention 
will result in many cases becoming 
latent or chronic, with the usual seque- 
lae so imfortunate in their efl^ects. 

{k) In those cases in which there is 
sagging of the postsuperior meatal wall 

A long curved incision extending across ^j^^ ^jj^ j^ j^^stoid Operation should 
the drumhead and into the meatus at the ^ -rx i • i 

upper portion. be performed at once. Delay is dan- 

gerous. If the infection is staphylo- 
coccal, the urgency for the pperative interference is not so great as in 
streptococcus infection. In the latter type of infection local treatment 
is usually unavailing, surgical procedures being required to effect a cure. 

{I) The ice-bag may be used over the mastoid process for from two to 
four hours when great pain is present. If no improvement follows, it 
should be discontinued and operative measures considered. Discon- 
tinue the ice when pus flows freely and the pain subsides. If the 
infection is streptococcal, its use will be unavailing. If it is staphylo- 
coccal, it may abate the infective process. 

(m) Leeches, natural or artificial, applied over the mastoid process and 
in front of the tragus are, perhaps, the most effectual method of pro- 
moting the reaction of inflammation and aborting the disease. (See 
Chapter VII.) 



ACUTE SUPPURATIVE OTITIS MEDIA IN INFANTS AND 
CHILDREN. 

In view of the fact that in 50 per cent, of the cases of measles there is 
an inflammatory affection of the middle ear in infants and young chil- 
dren, and that in all infectious diseases there is more or less inflamma- 
tion of the ear, it is proper to give a brief consideration of inflammations 
of the middle ear as found in infants and young children. 

The pathological changes foimd vary all the way from a simple catar- 



SUPPURATIVE OTITIS MEDIA IN INFANTS AND CHILDREN 717 

rhal inflammation, with swelling and cloudiness of the mucosa, to infil- 
tration and purulent secretion. The secretion is usually serous or sero- 
mucous, with some pus cells. 

The embryological conditions influencing the occurrence of the process 
in infants are (a) the presence of an opening in the upper segment of the 
drumhead, which does not always close before birth. In bathing, water 
may thus gain entrance into the tjonpanic cavity and set up an inflam- 
mation, (b) According to Weiss, the mucous membrane of infants is 
embryonic in type, and is, therefore, more liable to be affected by 
microorganisms. 

The cachexia of infancy, bronchitis, the infectious fevers, and chronic 
intestinal catarrh are also special causes of this affection in children. 

Coughing, vomiting, sneezing, and other violent respiratory efforts 
force infected matter through the Eustachian tube into the middle ear 
and excite catarrhal and suppurative inflammations. 

Otitis media is sometimes present in the newborn, and is probably due 
to the forcible entrance of amniotic fluids into the middle ear during 
delivery. 

Postnasal adenoids, enlarged or diseased tonsils, epipharyngitis, and 
coryza are conditions peculiarly prevalent among children, and con- 
tribute toward the causation of otitis media. 

Symptoms. — In infants with cachexia there are often no sub- 
jective symptoms. Objectively, the drumhead may be a little red- 
dened, especially about the short process and along the handle of the 
malleus. A smafl amount of slimy secretion may be found in the canal. 
It may be questioned whether the cachexia is the cause of the ear disease, 
or whether the ear disease is the cause of the cachexia. It is quite cer- 
tain, however, that even a mild suppurative process in infants is quite 
sufficient to cause pronounced disturbances of nutrition. Every case 
of malnutrition, peevishness, twisting of the head, or dropping it to 
one side should lead to the careful inspection of the ears of these young 
patients. Boring the head, or occiput, into the pillow, hanging the 
head to one side (affected ear), placing the hand to the affected ear, 
going to sleep when lying on the ear toward which the head is inclined, 
refusing to take the breast except on the side which allows the patient 
to lie with the affected ear against the bosom, all point to acute inflam- 
mation of the middle ear. The infant or young child cannot tell of his 
sufferings, l)ut if the physician carefully observes his actions, he will 
often find tliem speaking louder than words. 

In older children the symptoms are more pronounced, and just prior 
to perforation of the drumhead the pain is often excruciating. There 
may be vomiting, unconsciousness, and convulsions. In other words, 
signs of meningeal irritation are often present. This is accounted for 
by the free anastomoses of the })loodvessels of the temporal bone and tlie 
cranial cavity. 

When perforation takes ])lace there is an immediate relief of all the 
symptoms. 

The tendency to frecjuent relapses is a prominent characteristic of 



718 THE EAR 

otitic inflammations in infancy and childhood. After the tenth to the 
fifteentli year of age this tendency is not so marked. 

Treatment. — The treatment is ahnost the same as in aduks, with 
the exception that tympanic inflation is usually followed by great relief. 
When the inflammation is suppurative in character, the external meatus 
should be thorouglily cleansed with cotton-wound probes. The same 
treatment described mider acute suppurative otitis media and acute 
mastoiditis is applicable to these cases. Adenoids, when present, should 
be removed. 

CHRONIC SUPPURATIVE OTITIS MEDIA. 

Owing to the faulty instruction, or, more properly speaking, to the 
lack of systematic instruction in otology in most American medical col- 
leges, false ideas are prevalent concerning the true importance of chronic 
suppurative otitis media. The acute exacerbation is the only phase 
that ordinarily attracts serious consideration. When we recall the fact that 
none of the prominent life insurance companies will accept an applicant 
who is aft'ected with chronic otorrhea, we are brought face to face with 
the business man's view of the disease. He has found, after a careful 
study of the mortality tables, that applicants thus afi^ected do not live to 
the full term of their life expectancy. Both clinical observation and patho- 
logical findings bear out this conclusion. Clinically, we find chronic 
otorrhea attended by a sallow muddy complexion and acute exacer- 
bations, during which there is pain and mastoid tenderness, and an 
increased flow of pus, which subsides only to return again after many 
weeks, months, or years. In still other cases we find sinus thrombosis, 
septicemia, meningitis, brain abscess, etc., which often lead to a fatal 
termination. Bearing these facts in mmd, and their relation to what 
seems to be a simple and harmless chronic otorrhea, it becomes appar- 
ent that chronic suppurative otitis media is not to be thought of as a 
trivial or an unimportant disease 

Pathology. — It is very interesting, as well as instructive, to trace 
the pathological changes which occur in the mucous meml)rane, peri- 
osteum, and bony wall of the tympanum in the course of chronic sup- 
purative otitis media. They may be somewhat didactically stated as 
follows : 

(a) The first important change, after the hyperemia and slight infil- 
tration of the early stages, is the loss of the ciliated columnar epithelium 
in circumscribed areas, while in other portions the mucous membrane 
is much thickened, the ciliated epithelium often being several layers 
deep. In cholesteatoma the epithelium becomes flattened or epidermic 
in character. 

(h) Infiltration, thickening, dilatation of the bloodvessels, and the 
new formation of bloodvessels gradually take place. Tlie lymph ves- 
sels in the deeper layers also Ijecome dilated (Politzer). 

(c) The tubules of the acinous glands sometimes become closed by 
adhesive inflammation, and cvstic cavities are thus formed. 



CHRONIC SUPPURATIVE OTITIS MEDIA 719 

{d) The round-cell infiltration gradually changes to spindle cells, the 
inflammatory exudate being thus transformed into adhesive or cicatricial 
bands. 

(e) The periosteum remains intact for a period varying from a few 
weeks to a few years, although it is probable that in a majority of cases 
it loses its integrity within two years' time. 

(/) As the outer plate of the bone is nourished by the periosteum, it 
thus loses its nutrient fluids, and becomes carious and necrosed. Ulcer- 
ation of the mucous membrane, periosteum, and bone rapidly succeed 
one another until there is extensive destruction of the tissues, often 
exposing the sigmoid sinus, dura mater, or jugular bulb. 

{g) Avenues of infection of the cranial contents are thus opened and 
the patient's life is placed in imminent danger. 

(/i) All these changes may occur in the course of a chronic otorrhea, 
without any alarming symptoms whatsoever, such a state of aft'airs ex- 
isting for an indefinite time, perhaps for years, without giving rise to 
severe or alarming symptoms. On the other hand, dangerous compli- 
cations may occur at any time, speedily leading to a fatal issue. 

In addition to the foregoing pathological changes should be included 
the loss of the malleus and incus through atrophic and ulcerative degen- 
eration of the tendinous bands holding them in place. Being thus 
loosened, they may become necrosed and slough away through the 
large perforation in the drumhead. The perforation in the drumhead 
is usually large, often involving the entire membrana tensa, the size and 
location of the perforation varying with the location and nature of the 
pathological process in the middle ear and associated cavities. 

Symptoms. — The symptoms vary with the nature and location of 
the pathological process, as well as with the acuteness or chronicity of 
the same. In some cases the signs of the ear disease are so latent that 
but little thought and less attention are given to them. In others, there 
is a constant or intermittent flow of pus or mucopus into the external 
canal, with occasional twinges of pain. In still others, there are acute 
exacerbations, characterized by profuse pus discharge, often admixed 
with blood, and attended by pain, mastoid tenderness, and swelling. 
The chief difference between the types is in the degree of obstruction to 
free drainage and in the virulency of the microorganisms in the tympanic 
cavity and mastoid cells. So long as there is free drainage, and there are 
no virulent microorganisms jeopardizing the middle ear and cranial 
contents, the symptoms are not alarming in character. On the other 
hand, when free drainage is interfered with, and virulent infection 
supervenes upon the preexisting less virulent infection, the symptoms 
assume a most aggravated and alarming character. In other words, 
the so-called chronic suppurative otitis media assumes the proportions 
of an acute mastoiditis, with threatened intracranial complications. 

The Latent Form. — The symptoms in this type of middle-ear suppura- 
tion are scarcely appreciable to the patient, as there is little discharge 
and no pain or tenderness over the mastoid process. The patient 
often says there is no discharge, nor has tiiere been for manv months or 



720 "I'liE EAR 

years. Ocular inspection, however, will often show a small amount of 
pus in the middle ear and external auditory meatus. The amount is so 
small that it does not reach the concha, but is evaporated in the meatus, 
the dried remains being thrown off with the cerumen and epidermis. In 
these cases the drumhead is perforated, usually away from its margin, 
the size varying from a millet-seed to almost the entire membrane 
(pars tensa), though I have frequently observed cases of latent otorrhea 
w^hen the perforation was marginal. 

The Chronic Discharging Form. — There is a profuse but intermittent 
purulent discharge, sometimes admixed with mucus and blood. Acute 
coryza, epipharyngitis, and exposure to inclement weather increases 
the amount of discharge and its puruleiicy. Pain may be present, espe- 
cially when aggravated by either of the foregoing conditions. There is, 
at these times, a slight tenderness over the mastoid process, especially 
over the antrum. Inspection of the fundus meati shows pus filling it 
completely, or oozing through the perforation in the drumhead. If the 
drumhead is largely destroyed, and the pus has its origin in the attic, it 
may be seen to trickle down the long process of the incus into the atrium 
of the middle ear. After removing all the pus from the middle ear, the 
mucosa over the promontory may be seen as a yellowish-red reflex. 
Granulations or polypi may be present, filling the middle-ear cavity, or 
even protruding into the external meatus. I have seen cases in which 
the polyp protruded into the concha of the auricle. When polypi are 
present blood is often admixed with the secretions. 

There is more or less elevation of temperature during the subacute 
exacerbations. The skin is yellow and muddy, the whites of the eyes 
are slightly discolored, and a feeling of lassitude and mental inertia 
possesses the patient. 

Chronic Otorrhea with Acute Exacerbations. — This form of chronic sup- 
purative otitis media attracts attention on account of the exacerbations 
of pronounced pain, mastoid tenderness, and elevation of temperature. 
The patient and attending physician become conscious of the danger, 
which, indeed, may have existed for some weeks, months, or even years 
previously. What was previously regarded as a simple harmless 
discharge is now recognized as a threatened mastoiditis. There is a 
profuse flow of pus, perhaps admixed with blood, the mastoid is tender 
to the touch, either at its tip or over the antrum, and the temperature 
ranges from 1° to 4° above normal. There may be no distinct chill. 

The patient complains of lassitude, and is disinclined to pursue his 
vocation. He may be possessed with a feeling of apprehension or of 
impending danger. 

Having thus characterized the more obvious symptoms of the three 
most common types of chronic suppurative otitis media, the further study 
of the signs of this disease, and their significance in estimating the nature 
and location of the pathological changes, will be based upon the location 
of the perforation in the drumhead. 

Perforations, their Location and Significance. — To Leutert, Zaufal, 
and others we owe our knowledge of the pathological significance of the 



CHRONIC SUPPURATIVE OTITIS MEDIA 



721 



location of the perforations in the drumhead. It may be said, in gen- 
eral, that if the perforation is marginal, there is bone necrosis in the 
region of the perforation; and if the perforation does not involve the 
margin of the drumhead, but is near its centre, bone necrosis is absent, 
the case being one of simple suppurative otitis media. The informa- 
tion thus afforded, while not absolute, is nevertheless very valuable in 
arriving at a full knowledge of the case. 

The Clinical Significance of Chronic Perforations of the Mem- 
brana Tympani. — A central perforation (one not marginal) (Fig. 377) 
(a and b) usually signifies inadequate drainage and ventilation through 
the Eustachian tube, the perforation occurring at the point of least 




'>**■••'>'■ M 







# 



'•' im m.^ ^ 



The significance of centiai a/id marginal perforations of tlie membrana tympani. 

resistance. A central perforation is rarely attended by necrosis of 
the l)ony walls of the cavum tympani or of the ossicles, and may be 
successfully treated without major surgical interference. According to 
Leutert, all central perforations indicate tubal infection. 

(c) While this is a central perforation, it is located over the tympanic 
orifice of the Eustachian tube, and is the result of continual middle-ear 
infection from the tuV)e. The Eustachian tube is probably infected from 
the epipharyngitis which is present. The epipharyngitis may be due 
to the presence of adenoids or their remnants, or to diseased tonsils, or 
to ethmoiditis and sphenoiditis. A perforation of the membrana tym- 
pani over the tympanic orifice of the Eustachian tube should, therefore, 



722 't^JIE EAR 

direct the attention of the aural surgeon to the epipharvnx and the contig- 
uous structures, rather than to the tympanic cavity. A radical mas- 
toid operation upon a case with a perforation at this point would, in 
all probability, fail to check the otorrhea. An attempt to close the 
tympanic orifice of the Eustachian tube at the time of the radical opera- 
tion would, in all probability, meet with failure, as the continued infec- 
tion from the epipharynx would prevent closure. The rational treatment 
of such a case would be to cure the sinuitis, remove the adenoids and 
tonsils, or to adopt such other remedial measures as will cure the 
epipharyngitis. 

(d) A perforation of the inferior margin of the membrana tympani 
signifies necrosis of the inferior wall or floor of the tympanic cavity. 
The only vital structure in this region is the jugular bulb (Fig. 377). 
As the bony wall separating the tympanic cavity and the jugular bulb is 
usually quite thick, the perforation may signify nothing more than 
necrosis of the floor of the tympanic cavity, a region which is accessible 
to curettement through the external meatus. In rare instances, however, 
the jugular bulb is separated from the tympanic cavity by only a thin bony 
wall, or the wall may be entirely absent. A marginal perforation at this 
point should, therefore, be regarded as suspicious of necrosis from jugular 
bulb disease, especially if septic symptoms are present. The exploration 
and curettement of the floor of the tympanum should in such cases be 
prosecuted with caution. 

(e) A perforation of the membrana flaccida immediately above the 
short process of the malleus usually signifies necrosis of the head of 
the malleus, a structure in close apposition to the perforation. 

(J) A marginal perforation immediately above the short process of 
the malleus and extending to the superior wall of the meatus usually 
signifies necrosis of the tegment tympani (roof of the attic). 

(g) A perforation of the membrana tympani at the margin of the 
posterior superior quadrant of the membrana tympani usually signifies 
necrosis of the incus and of the bony wall of the antrum. 

(h) Numerous small perforations near the margin of the membrana 
tympani are usually significant of a tuberculous otitis media. 

From the foregoing data it may be inferred that a central perfora- 
tion signifies a simple infectious process in the ca\ami tympani, whereas 
a marginal perforation usually signifies bone necrosis. ^larginal perfor- 
ations are, therefore, indicative of a more serious process in the middle 
ear (cavum tympani) than is indicated by a central perforation. The 
entire absence of the membrana tympani is equivalent to a marginal 
perforation, and is strongly suggestive of bone necrosis. 

While the significance of chronic perforations is generally to be inter- 
preted as given in the foregoing paragraphs, it should not be inferred that 
the location of the perforation is an infallible guide to the condition 
present in the middle ear and mastoid cavities. All the other clinical 
phenomena should be taken into consideration, and a conclusion be 
drawn from the entire symptom complex. 



CHRONIC SUPPURATIVE OTITIS MEDIA 723 

Prognosis as to Hearing. — In simple or central perforations the hear- 
ing may be but slightly affected after the suppurative process is 
relieved. In the complex or marginal perforations, with bone necrosis, 
the hearing is usually diminished after the radical operation, whereas it 
is greatly improved after the Heath operation. The patient should be 
made to understand that, while every effort will be made to maintain or 
improve the hearing, the chief concern is to check, or to cure, the suppu- 
rative process, which, if allowed to run its course, may jeopardize both 
the health and life of the patient. 

According to Clarence Heath, of London, many of the cases hereto- 
fore operated by the radical method may be cured by his method of oper- 
ating. (See Meatomastoid Operation.) In addition to a less radical 
procedure, he claims for his operation that the hearing is not only 
conserved, but that it is usually restored to near the normal. My own 
experience with the meatomastoid operation is limited to twelve cases, 
and thus far the results obtained have been all that he claims. The 
cases selected by me for this operation have been those in wliich the 
ossicles were not markedly necrosed, though the perforation in some 
was marginal. The prognosis as to the permanent cure of the disease 
by this operation is still open until further experience demonstrates 
its exact place in otological surgery. That the hearing is preserved, and 
usually greatly improved by tliis method of operating, is, I believe, fairly 
well demonstrated. 

Treatment. — The treatment of chronic suppurative otitis media 
does not offer a brilliant therapeutic field. In spite of all that can be 
done with local treatment, the discharge often persists, or, if checked, 
recurs within a few weeks or months. Many so-called "cured cases" 
are in reahty only latent, and with the first "cold in the head," or other 
local irritation, become active again. This tendency is so strong that 
many otologists have regarded the persistence, or the tendency to recur- 
rence, as an indication for the radical mastoid operation. While this is 
])rol)ably an extreme view, it is, nevertheless, a more rational one than 
the view held by some, that most cases of chronic otorrhea may be cured 
by simple local treatment, or by simple operative measures through the 
external auditory meatus. A.s a matter of fact, each case should be dil- 
igently studied as to the local morbid conditions, and as to the main 
etiological factors. Furthermore, the pathological laws underlying infec- 
tious processes in cavities lined with mucous mem])ranes should be well 
(•oiisidered. (See Chapter VI.) 

The treatment of clii-oiiic suppurative otitis media will be studied, 
with the foregoing fads in uiiiid, under the following headings: 

The Treatment of Chronic Otorrhea with a Central Perforation of the Mem- 
brana Tympani. Chi'oiiic sii[)j)ui-;ili\(' otitis media with a centi-al perfora- 
tion of the mcnibfaiia fyni|)ani fFig. 377 a, l>, c) usually signifies a sim])le 
infection of the niiicoiis lucnibrane of the middle ear without involve- 
ment of the bony tissue of the t\-iiipanic walls, or of the ossicles, and is, 
therefore, often amenable to siini)lc local trcatincnt. Ai; exce])tion to 
this should be made wlieii the jjci'foration is located o\-er (he tynij)anic 



724 THE EAR 

orifice of the Eustacliian tube (Fig. 377 c). A perforation in this region 
indicates a suppurative process in the pAistachian tulie, hence the middle 
ear cannot be cured wliile the tubal infection continues. In such cases 
the first attention should be given to the Eustachian tube and the condi- 
tions giving rise to its involvement (adenoids, epipharyngitis, sinuitis). 

The treatment of otorrhea with a central perforation of the membrana 
tvmpani is, therefore, divided into two classes, namely, (1) otorrhea 
with a central perforation, other than over the tympanic orifice of the 
Eustachian tube, and (2) chronic otorrhea with a central perforation of 
the membrana tympani over the tympanic orifice of the Eustachian tube. 

1. The treatment of chronic otorrhea with central perforation of the 
membrana tympani which is not over the tympanic orifice (Figs, a and b) 
of the Eustachian tube is Imsed upon (cardinal principles) free drainage, 
the removal of the morbid material, and the maintenance of aseptic con- 
ditions wdiile repair is taking place and is as follows: 

Dry Gauze Dressings. — In 1880-82, Dr. Spencer, of St. Louis, ad- 
vocated the use of strips of dry gauze in the treatment of acute and 
chronic suppurative otitis media. Since then the same method of treat- 
ment has been lu'ged l)y Gradinego, Pierce, Gradle, and others. The 
gauze promotes drainage of the secretions, and at the same time pre- 
vents further infection through the auditory meatus. 

Fig. 378 



r. A. HARDY ikCO. 

Bane-Allport gauze packer. 



The fundus of the meatus should be mopped dry with a cotton-wound 
applicator before the strip of gauze is applied. 

The end of the gauze is then carried to the membrana tympani with a 
probe packer (Fig. 378). The meatus is then loosely packed with the 
gauze and a small piece of cotton placed over it. The gauze should be 
removed every twenty-four to forty-eight hours and the secretions thor- 
oughly removed with a cotton-wound applicator. A new strip of gauze 
is then applied as before. 

In many cases the drainage and protection afforded hj the gauze leads 
to the rapid disappearance of the infection and to repair. The perfo- 
ration sometimes voluntarily closes by granulation from its edges. In 
other cases it persists, and may be closed by the application of a 33 per 
cent, solution of trichloracetic acid to its edges at intervals of a few days. 
No attempt should be made to close the perforation until the secretions 
are normal. 

In addition to the foregoing method of treatment, alcohol in varying 
strength may be instilled into the middle ear through the meatus. 

The middle ear may also be cleared by inflation through the Eusta- 
chian tube if the otorrhea persists after several treatments. 

2. The treatment of otorrhea with a central perforation over the 
tympanic orifice of the Eustachian tube (Fig. 377 c) is more complicated 
than when the central perforation is otherwise located. The otorrhea is 



CHRONIC SUPPURATIVE OTITIS MEDIA 725 

perpetviated by the discharge of infected secretion from the Eustachian 
tube into the tympanic cavity, and cannot be cured without first over- 
coming the infection and discharge from the Eustachian tube. The 
mucous membrane of the Eustachian tube, when normal, is covered by 
cihated cohunnar epitheUum, which propels the secretions toward the 
pharyngeal orifice of the tube. In chronic mfectious processes the cilia 
are lost, or their wave-like motion is inhibited, and the secretions flow 
in the direction of least resistance. The isthmus of the tube forms a bar- 
rier to the downward flow of the secretions from the tympanic end of the 
tube, hence they are poured into the tympanic cavity. The constant 
irritation of the membrana tympani over the tympanic orifice of the tube 
leads to perforation of the membrana tympani at this point. The first 
indication in these cases is to remove the cause of the tubal infection and 
inflammation. 

If the tubal infection is due to a constriction at the isthmus of the tube, 
the tube should be dilated with bougies, and astringent and antiseptic 
solutions forced through it with a Weber-Liel catheter. 

If the tubal infection is due to the presence of epipharyngeal adenoids, 
or their remnants, they should be removed. 

If the infection is due to an epipharyngitis, it should receive appro- 
priate treatment. 

And, finally, if the tube is infected by the discharge from diseased 
nasal sinuses, especially the posterior ethmoidal and the sphenoidal 
sinuses, this condition should receive appropriate surgical treatment. 

Having removed the cause of the tubal infection, the infection tends to 
disappear with little or no other treatment. In some cases, however, 
the infectious process in the Eustachian tube is attended by such pro- 
nounced tissue changes that additional local treatment is necessary. 

The local treatment of the infected Eustachian tube and tympanic 
cavity consists in the use of the dry gauze treatment and in the use of 
mild astringent and antiseptic solutions througli the Eustachian tube, 
a Weber-Liel catheter being used for this purpose. The Weber-Liel 
catheter consists of a small, long, flexible hard rubber catheter, placed 
inside of a larger catheter of the usual length. The larger catheter is 
passed to the pharyngeal orifice of the tube, and the smaller one is 
introduced through it to the isthmus of the Eustachian tube. A small 
syringe, filled with an alkaline antiseptic solution, is then attached to 
the smaller catheter and forced througli tlie Eustachian tube into the 
middle ear. This course of treatment, following the removal of the con- 
ditions causing the tubal and nn"ddle-ear infection, is often attended by 
a coin])lete cure of the cln-onic otorrhea. 

The Treatment of Chronic Otorrhea with Marginal Perforations of the 
Membrana Tjrmpani. — As marginal pei-forations of the membrana tym- 
pani usually signify necrosis of tlie ossicles, the bony tympanic walls, 
the tegmen tympani or tegmen antri, and the other contiguous bony 
structures, the treatment of chronic otorrhea thus characterized is not 
so simple as in central perforations. The same fundamental princi])les 
of treatment should, however, be observed. The drainage and the 



726 THE EAR 

removal of the morbid material are absolutely essential to the success of 
the treatment. The methods of establishing drainage and of removing 
the morl)id material are radically different, for anatomical and patholog- 
ical reasons, from those pursued in otorrhea with central perforations. 
It is obviously impossible to materially facilitate drainage with dressings 
in the external auditory meatus when the obstruction is in the antrum 
or aditus ad antrum. It is equally obvious that the morbid material 
cannot, under such conditions, be removed through the auditory meatus. 
Such measures must be adopted as will expose these regions to the sur- 
geon's instruments. 

1. When the perforation is just above the short process of the malleus 
(Fig. 377 e), the head of the malleus is probably necrosed, and the malleus 
should be removed. (See Ossiculectomy.) A 2 per cent, solution of 
the nitrate of silver may, however, be injected through the perforation 
to promote healthy granulation, with the hope of healing the diseased 
ossicle and thus avoiding the necessity of removing it. 

2. When there is a perforation at the upper margin of the membrane 
(Fig. 377 /), and it involves not only the membrana flaccida but the supe- 
rior wall of the auditory meatus, the tegmen tympani is probably ne- 
crosed. Even in these cases osseculectomy is sometimes attended by a 
cure of the chronic infection and otorrhea. If the floor of the attic is 
blocked, the removal of the malleus and incus may establish free drain- 
age, and thus effect a cure. In other instances, ossiculectomy w^ill not 
effect a cure, probably because the case is complicated by epipharyngitis, 
salpingitis, or necrosis of the antrum walls. Ossiculectomy is, there- 
fore, only applicable to those cases in which the tegmen tympani is alone 
necrotic, the complicated cases being amenable to the meatomastoid or 
the radical operation, preferably the radical operation. 

3. Wlien the chronic otorrhea is attended by a marginal perforation 
at the postsuperior quadrant of the membrana tympani, as shown in 
Fig. 377 g, necrosis of the antrum is probably present. The incus also 
may be necrosed. To establish drainage, and to remove the morbid 
material, either the radical or the meatomastoid operation should be 
performed. It is barely possible, however, that by irrigating the attic 
through the perforation, drainage may be established through the aditus 
ad antrum and a cure be effected. In these cases the meatomastoid 
operation appears to be well adapted. 

4. With a perforation at the inferior margin of the membrana tym- 
pani (Fig. 377 d), the necrosed bone may be removed with a curette 
introduced through the auditory meatus. If septic symptoms are 
present, the floor of the tympanic cavity should be cautiously explored, 
as the necrosis may be due to an extension from the jugular bulb. If 
septic symptoms are present in such a case, the rational procedure would 
be to perform either the radical or the meatomastoid operation, and 
then expose the sigmoid portion of the lateral sinus and the jugular 
bulb. If septic symptoms are absent, the floor of the tympanum should 
be explored with a blunt probe for necrotic bone, and if found it should 
be carefully removed with a bent curette through the perforation. The 



CHOLESTEATOMA 727 

perforation should be previously enlarged by two divergent incisions. 
After curettement, the meatus should be loosely packed with sterile 
gauze, as recommended in simple central perforations. The gauze 
should be removed daily, the meatus freed of secretions, and repacked 
with gauze, until the necrotic area is healed and the perforation closed. 
If the secretions disappear and the perforation persists, it may be closed 
by the application of a 33 per cent, solution of trichloracetic acid. 

5. Otorrhea attended by a perforation of the membrana tympani at 
its anterior margin usually signifies necrosis in this region. As the 
carotid artery passes upward through the temporal bone near the ante- 
rior boundary of the cavum tjanpani, curettement should be cautiously 
performed m this region (Fig. 377). 

6. Numerous pinpoint perforations of the membrana tympani usually 
signify a tuberculous otitis media. 

Other Methods of Treatment. — Curettage of the attic via the external 
auditory meatus should be undertaken with great reluctance and cau- 
tion. If granulations are present, it is quite probable that the tegmen 
tympani is necrosed and that the granulations are thrown around and 
over it to wall off the invading pathogenic bacteria from the meninges. 
The removal of the granulation tissue without at the same time estab- 
lishing free drainage of the secretions from the tympanic cavity might 
lead to infection of the meninges. Such a condition may be much more 
successfully and safely (and I may add more conservatively) treated by 
the radical or the meatomastoid operation. 

The alcohol treatment has been held in high esteem in chronic suppu- 
rative otitis media. Its field of usefulness is chiefly Hmited to central 
perforations, except when it is over the tympanic mouth of the Eustachian 
tube (Fig. 377 c). In otorrhea with a marginal perforation, alcohol only 
relieves the symptoms, but does not cure the disease. 

The alcohol may be used in various dilutions, ranging from 25 to 95 
per cent., beginning with the milder solution to avoid pain, and then 
using the stronger solutions. The alcohol should be left in the cleansed 
ear for twenty minutes at each treatment. 

Alcohol holding boric acid or iodoform in solution or suspension may 
be used in otorrhea with a central perforation, though it is probable 
that its therapeutic value is not increased by the addition of the boric 
acid or iodoform. 

In fetid otorrhea the instillation of the compound tincture of benzoin 
may ])e used to remove tiie fetor. It is also an antiseptic and astringent, 
and acts favoral)ly upon the diseased tissues. The fundus of the meatus 
should be mopped dry ])efore applying the compound tincture of benzoin. 

When the mucous membrane of the middle ear has undergone fungoid 
graiuilation degeneration, a 05 per cent, solution of carbolic acid may be 
(h'o])])e(l into the ear, care being exercised to prevent the acid coming into 
contact with the mental skin. At the expiration of one minute alcohol 
should bo instilled into the ear to check the action of the acid, after which 
the car should be iiiopix'd witli a cotton-wound applicator until dry. 
The meatus should Ihcii Ix- loosely packed with dry, sterile gauze. 



728 ■ THE EAR 



CHOLESTEATOMA. 



Cholesteatoma of the middle ear is characterized by the formation of 
masses of epidermoid cells arranged in concentric layers between which 
are found cholesterin crystals. 

Etiology. — About tlie year 1840, J. Miiller described new formations 
in the temporal bone, resembling pearly growths. They were composed 
of concentric layers of epidermoid cells with cholesterin crystals between 
them. They are commonly found in the antrum and attic, and are' 
covered by a delicate membrane which is closely adherent to the peri- 
asteum of the bone to which they are attached. This variety is known as 
primary cholesteatoma, as it seems to have its origin in the cavity where 
it is found. The secondary and most common type is due to an exten- 
sion of the epidermis of the external meatus and membrana tympani 
into tlie middle ear through a perforation in the drumhead. 

Primary Cholesteatoma. — Primary cholesteatoma is variously believed 
to be heteroplastic, possibly arising from the epithelium of the ductus 
vestibule; that is, it is a remnant of the second visceral cleft left behind 
after its closure. ]\Iild inflammatory action in the middle ear favors their 
growth, whereas severe inflammation hinders it. Primary cholesteatoma 
is probably (juite rare. Its existence might well be dou])ted if it were not 
for the fact that eminent observers have made fidl and detailed reports 
of such cases. Other equally eminent observers claim there is no such 
condition, all cases being secondary to suppurative processes in the 
tympanic cavities. Von Troltsch, Habermann, Politzer, and others 
hold tliis opinion. 

Secondary Cholesteatoma. — This is the type found in practice, the 
primary form l)eing chiefly limited to the literature. The masses in 
all probability have their origin from extensions of epidermis from the 
external meatus and drumhead. The conditions favoring this extension 
are: 

(a) A marginal perforation of the drumhead. 

(h) A mild chronic suppurative inflammation of the mucosa of the 
middle ear. 

(c) A fistulous opening in the posterior or superior wall of the meatus. 

{d) Adhesions at the margin of the perforation. 

(e) Adhesions of the end of the handle of the malleus to the pro- 
montory. 

(/) Aural polypi. 

Perforations in the posterior portion of the membrana flaccida are espe- 
cially liable to be followed by cholesteatoma on account of the tongue- 
like or thickened extension of epithelium from the superior wall of the 
meatus to the drumhead at this point. Politzer reports a case in which 
the growth seemed to have its origin in a fistulous opening in the mastoid 
process. 

The cholesteatomatous masses are of a pearly gray color, and slightly 
lustrous. Upon section they are found to be composed of concentric 



CHOLESTEATOMA 729 

layers of epidermic cells intermixed with detritus and cholesterin crystals. 
If the conditions are favorable the masses grow larger and larger, causing 
eccentric pressure atrophy of the bony walls of the cavity involved. 
In some cases there is bone necrosis, which may thus expose the brain, 
lateral sinus, and labyrinth to the infection contained in the masses. 
They are broken down in their centres, richly odorous, and loaded with 
pathogenic microorganisms. The central breaking down is due to 
putrefaction. 

Aural polypi, with mild suppurative inflammation, are often attended 
by cholesteatomatous formations. If there is an active or profuse pus 
discharge, the formations are checked or altogether dissipated. The 
free drainage incident to a profuse discharge seems to prevent the further 
inward extension of the epidermic process, the masses gradually dis- 
appearing, and the cavity healing with a layer of flat epithelial covering 
or matrix. The size of the cholesteatomatous masses varies from a 
hemp-seed to a large walnut. Their shape either conforms to that of the 
cavity in which they form, or they are round, oval, or very irregular in 
outline. 

Extensions of the cholesteatoma into the Haversian canals have been 
demonstrated, which may, in part, account for the marked tendency to 
recurrences in spite of thorough operative interference. E. B. Dench has 
called attention to the presence of small masses of cholesterin crystals 
without epithelial cells, the etiology and pathology of which are not 
known. He reported two such cases operated by the radical method 
with good results. 

Sjonptoms. — The masses may be present for years without giving 
rise to distinct s}^Tnptoms. Sudden swelling of the mass from the 
entrance of moisture into the external meatus, as from sweating, bathing, 
syringing, etc., may cause pressure symptoms, as pain and necrosis. 
In this event there may be a feeling of fulness or pain in the affected ear, 
with headache, nausea, vomiting, staggering gait, fever, and aprosexia. 
The moisture causes the horny cells to swell, and the sudden pressure 
thus exerted causes the above signs of pressure and of intracranial 
irritation. 

Inspection of the meatus shows it to be more or less filled with a pearly 
gray mass, admixed with granulations or aural polypi. If a portion is 
removed and placed in water, it appears as shreds of delicate tissue 
with the golden grains of cholesterin, which are characteristic of this 
growth. If the mass is favorably located, it may be removed with the 
syringe or ear spoon. In other cases it is necessary to do the radical 
mastoid operation to eradicate it. Even then it may })e necessary to 
repeat the operation one or more times before a satisfactory result is 
obtained. 

The termination of cholesteatoma may be by (a) epidermization after 
the spontaneous or instrumental removal of the mass; (/;) it may be 
forced through the Eustachian tul)e into the epipharynx, or into the 
maxillary articulation through the anterior wall of the meatus; (c) it 
often breaks through the walls of the scniicirculiir canals (Jansen); 



730 THE EAR 

{(l) in some cases it pushes its way through the external plate of the 
mastoid process and presents the appearance of a mastoid abscess; 
(e) in still other cases it may cause necrosis of the tegmen antri and 
tympani and cause death from involvement of the cranial contents; (/) 
death may also result from sepsis arising from the absorption of the 
retamed secretions; (g) and from meningitis, brain abscess, sinus throm- 
bosis, or thrombosis of the jugular vein; {h) and through the digastric 
fissure. 

Diagnosis. — The diagnosis may be made by the removal of the growth 
and subjecting it to microscopic examination. This may be done with 
a curette, probe, or syringe when the growth is in the middle ear. If in 
the antrum, it can only be removed by mastoid operation. Sydacker 
has called attention to the sedimentation of the washings of the ear, 
which, when microscopically examined, show the epithelial cells with 
neuclei staining very faintly. Particles of bonedust are also shown as 
highly refractile crystals. Briihl-Politzer have called attention to the 
use of a chloroform solution of the cholesteatomatous masses in which 
the cholesterin produces a greenish discoloration. 

Prognosis. — The prognosis is bad. In those cases in which there is a 
spontaneous or instrumental expulsion of the cholesteatoma the cavity 
usually becomes refilled with it. Even after the most thorough radical 
operation the disease may persist. This is not at all difficult to under- 
stand when we recall the fact that the cholesteatoma forces its way into 
the Haversian canals of the bone, thus effectually forming focal centres 
from which it may extend again. Sac-like prolongations into the bone 
have also been observed, thereby making it difficult to entirely eradicate 
the process. The uncertainty of cure leaves the possible complications, 
as meningitis, brain abscess, pyemia, sinus and jugular thrombosis, 
a menace to the health and life of the patient. Cures are, however, 
frequently effected, and we are warranted in attempting thorough 
surgical measures for its relief. 

Treatment. — The treatment in uncomplicated cases may be begun 
with the removal of the cholesteatoma through the perforation in the 
drumhead with small ciu'ettes, ear hooks, etc., or with a syringe. In 
some instances it is found to be advantageous to force sterile fluid through 
the Eustachian tube into the middle ear, thus getting the force of the 
stream of water behind the mass, and forcing it into the external meatus. 

Should polypi be present, they should be removed. If there is necrosis 
of the ossicles, they shoidd be removed. Adhesions of the edges of the 
j)erforation to the inner wall of the tympanum, or adhesions of the end 
of the handle of the malleus to the promontory shoidd be broken down. 
After having removed the tumor the parts should be dusted with an 
antiseptic powder. 

Should these simple measures prove ineffective, recourse must be had 
to the radical mastoid operation, elsewhere described in this work. The 
meatomastoid operation is not indicated. As the chief object of the 
meatomastoid operation is to preserve or improve the hearing, and as this 
object is defeated by the unavoidable dislocation of the ossicles in remov- 
ing the cholesteatoma, the meatomastoid operation is contra-indicated. 



CHAPTER XLIV. 

THE SEQUELS OF SUPPURATIVE OTITIS MEDIA, MASTOIDITIS, 
AND CHOLESTEATOMA. SUPPURATION OF THE LABYRINTH. 

DISEASES OF THE MASTOID PROCESS. 

Primaey disease of the mastoid process is very rare. Diseases of the 
mastoid are usually secondary to a suppurative process in the middle ear. 
Pneumococcus and more especially influenza infection sometimes appear 
in the mastoid process without first affecting the middle ear. As a 
matter of fact, all, or nearly all, suppurative middle-ear inflammations 
probably also involve the mastoid cells. 

It is difficult to separate the suppurative processes of the middle ear 
from those of the mastoid cells. Clinically the disease is subdivided upon 
an arbitrary basis according to the focal manifestations present. The 
anatomical distribution of the pneumatic spaces of the temporal bone is 
so complex that it is advantageous to subdivide suppurative inflamma- 
tions within them according to the focal centre of involvement, while, 
on the other hand, it is more rational to regard the process as one disease 
regardless of the focal symptoms. The antrum is perhaps the axial 
centre of the pneumatic spaces of the ear, the mastoid cells communicat- 
ing with it posteriorly, while the attic and atrium (middle ear) communi- 
cate with it anteriorly. If the case requires external surgical treatment, 
it is most centrally attacked by way of the antrum, the operative field 
being extended posteriorly into the mastoid cells and anteriorly into the 
middle-ear, according to the conditions present. If the disease is mild 
and focalized in the middle ear, it may be regarded as middle-ear disease. 
In those acute cases terminating without focal mastoid symptoms it has 
been customary to speak of them as acute otitis media regardless of the 
fact that the mastoid cells were also involved. 

With this understanding the various diseases of the mastoid process 
will be described. 



ACUTE SIMPLE MASTOIDITIS WITHOUT INTRACRANIAL LESION. 

Symptoms. — It is probable that in nearly every case of acute infection 
of tlic middle ear the mastoid cells and antrum are also involved. It is 
chiefly in those cases in which free drainage is interfered with that the 
mastoid symptoms become manifest. The mastoid symptoms are 
chiefly those of pressure from retention of tlie secretions within the cells. 
They are pain, rechiess, swelling, and tenderness upon pressure or 



732 THE EAR 

percussion over the mastoid process. When such symptoms supervene, 
the original disease sinks into a place of secondary importance, while 
the secondary conditions come forward as the object of greatest interest. 
The disease is no longer called otitis media, but is called mastoiditis. 

There is a sudden rise of temperature accompanied by rigors of 
varying intensity. Many cases, however, have but slight elevation of 
temperature at any time during the disease. In others the rise is as 
high as 104°. 

The pain originates behind the auricle and radiates toward the teeth 
and slioulders (Politzer), the occiput, neck, and face. Mastication may 
be painful on account of an involvement of the bony portion of the 
external meatus, which is in close proximity to the glenoid fossa. 

The sternocleidomastoid and the other muscles of the neck attached 
to the mastoid account for the pain upon movements of the head. 
Torticollis may be present in mastoiditis. It is due to a fixation 
of the muscle to avoid pain upon movement. It has been shown by 
others (Broca and Lubet-Barbon) that it is sometimes due to enlarge- 
ment of the cervical glands and to infection from measles, in which otitis 
media was not present. In the case of measles the torticollis was prob- 
ably due to glandular enlargement from infection. 

Schwartze calls attention to the intolerance of pressure over the whole 
mastoid, but more particularly immediately below the zygomatic ridge 
(antrum). 

The appearance of the skin over the mastoid process becomes red and 
swollen, and can no longer be picked up between the fingers. In some 
cases the auricle stands forward, even approaching a right angle to the 
side of the head in some instances. In these cases a subperiosteal 
abscess is present. 

The aural discharge may be scanty or profuse. Redness and swelling 
of the postsuperior wall of the external meatus near the drumhead are 
commonly present. This condition is variously spoken of as the "dip," 
"chute," or "bulging" of the postsuperior wall. Under the pathology 
of the mastoid I have already referred to the presence of pneumatic 
mastoid cells (the border cells), which are found between the antrum and 
meatus. These break down, and the retained secretions cause the wall 
to thus "dip" or "bulge." This sign is pathognomonic of mastoiditis 
of a destructive type, and is therefore a strong indication for an immediate 
operation (Fig. 375). 

I The diagnostic value of this sign has been emphasized by Schwartze, 
Macewen, Holmes, Sheppard, Duplay, and many others. Politzer 
thinks it is not necessarily an indication for the mastoid operation, while 
Schwartze, Broca, and Luber-Barbon hold the contrary view. 

Delay in operating subjects the patient to almost certain danger, 
even though it does not become apparent for years. I can recall but 
one case (following an attack of influenza) in which the "dip" and 
all other signs of middle-ear and mastoid disease seemed to disappear. 
I use the word "seemed" advisedly, for there is little doubt as to a 
subsequent recurrence in such cases. I fully recognize that there are 



MASTOIDITIS WITHOUT INTRACRANIAL LESION 733 

exceptions to all rules, and that this instance may be one of them. Never- 
theless, the rule and not the exceptions should guide us. 

Perforation of the drumhead nearly always exists. It is usually 
small and filled with pus and debris, which pulsates synchronously with 
the heart beat. 

Granulations sometimes protrude through the opening and block 
the discharge of the secretion. The removal of the granulations is often 
sufficient to establish free drainage and relieve the acute mastoid symp- 
toms. It may be doubted whether it really cures the mastoiditis, as this 
may remain in a latent form for years before culminating in an alarming 
exacerbation. 

In still other cases the perforation is large and discharges but little 
pus. In these cases the aditus ad antrum is obstructed. This is of 
interest as a diagnostic and prognostic point. It enables the attending 
physician to locate the obstruction prior to the operation, and to deter- 
mine whether relief may be expected from a simple middle-ear operation 
(removal of the granulations) or whether it will be necessary to do a 
postauricular mastoid operation to open the aditus ad antrum. 

Sj>ontaneous cures should he looked upon with suspicion, as in nearly 
every case it amounts to nothing more than a remission. Politzer, 
Schwartze, Duplay, Holmes, Ballenger, Stucky, Macewen, Dench, 
St. John Roosa, Hollinger, Pierce, Whiting, and others report recurrences 
in cases which had seemed to be cured. 

One should be extremely modest in claiming to have "cured" mastoid- 
itis without surgical intervention. That such a termination may occur 
cannot be denied, but such a termination is rare. 

Treatment. — If the case is seen before spontaneous perforation of 
the eardrum has occurred it should be freely incised at the points of 
greatest bulging. This is done to promote the reaction of inflammation 
and to relieve the pressure and the tissue necrosis. The tissues in the 
presence of an acute infectious process are very susceptible to necrosis 
while pressure is maintained, hence the necessity of an early incision. 
The incision should be a long and curved one, so as to make as free an 
opening as possible. Some writers advise carrying the incision into the 
meatus (Fig. 376), thus cutting through the annular plexus of vessels 
surrounding the attachment of the membrana tympani. The free bleed- 
ing thus produced acts favorably upon the progress of the inflammatory 
process; that is, it promotes the reaction of inflammation and favors free 
drainage. Some writers condemn the extension of the incision through 
the annular plexus of vessels, on account of the liability of extending 
the infection through these vessels. If there is a virulent streptococcus 
infection the incision should not be thus extended, while it may be so 
extended in the milder infections. Personally, I do not often carry the 
incision into the external meatus. If the destructive process is not great, 
there is no necessity for so doing, whereas if the destructive process is 
great, there are dangers attending such a procedure. 

Cold aj)plioations by means of an ice-bag or a Leiter coil may be made 
over the mastoid process if the case is seen witliin thirty-six hours of the 



734 THE EAR 

onset, and if there is great pain and scanty discharge of pus. If applied 
after this time, it has httle or no therapeutic value. Cold reduces the 
inflammatory reaction, diminishes the swelling of the mucous membrane, 
and thus overcomes the obstruction to the flow of the secretions. If the 
applications fail to remove the tenderness and pain and to establish a 
more free discharge of secretions, it should be discontinued and leeches 
applied. Indeed, leeching is much more efficacious than ice. In some 
cases the cold applications mask the symptoms and lead the surgeon to 
believe the disease is conquered. The real problem in acute mastoiditis 
is not to bring about an abatement of the acute symptoms, but to relieve 
the patient of the suppurative process by promoting the reaction of 
inflammation. Even though the acute symptoms disappear and the 
patient appears to be well, but still has an ear discharge, a cure is not 
effected. The patient should have no ear discharge or perforation of 
the eardrum. Too much attention has been given to the relief of the 
acute symptoms, and too little to the cure of the suppurative process. 
The acute symptoms will usually subside if nothing is done for the patient. 
It is true that in most cases less damage follows if appropriate attention 
is given to the acute symptoms during their manifestation. Eradication 
of the suppurative process should be the ultimate aim of the treatment. 
The attending surgeon should not be satisfied, therefore, to relieve the 
pain, redness, tenderness, and temperature, but should also institute such 
remedial measures as will modify the acute symptoms and at the same 
time eradicate the infection. 

To accomplish the foregoing results it may become necessary to perform 
a mastoid operation, which, if done at a sufficiently early period, need 
not be an extensive or formidable affair. On the other hand, the delay of a 
few days or weeks may make it necessary to perform a radical operation. 
The cold applications, the incision of the eardrum, leeching, etc., should 
therefore be tried early, so as to determine as quickly as possible whether 
the disease can be aborted. If the mastoid is still tender upon pressure 
and the discharge continues, there is a strong probability that the acute 
process will merge into a chronic one if surgical interference is not insti- 
tuted. The point I wish to emphasize is that the simple operation may be 
performed within the first three or four weeks of the onset of the disease, 
whereas if delayed to a later period the meatomastoid operation may be 
necessary. There are hundreds of cases of chronic otorrhea which would 
never have existed had they been operated on sufficiently early, or if the 
operation has been delayed too long to be cured by the simple mastoid 
operation, had the meatomastoid or the radical operation lieen performed. 
Just when to operate, and the kind of an operation to perform, is the great 
problem in acute suppurative otitis media complicated by mastoiditis. It 
should also be stated in this connection that all cases do not need to be 
operated upon. Many get well without such interference. If the pain 
over the mastoid persists after the incision of the membrana tympani and 
the use of the leeches, an operation is indicated; that is, the disease will 
probably persist as a chronic otorrhea unless an operation is performed. 
The object of the operation is to prevent further mischief, rather than to 



MASTOIDITIS WITHOUT INTRACRANIAL LESION 735 

avert immediate danger. It is not good practice to wait for dangerous 
symptoms, as the mortality under these conditions is much higher. 
Chronic otorrhea is a signal of impending disaster, and every effort should 
be exerted to cure it, even though a radical operation is necessary to 
accomplish it. 

The Leiter coil (Fig. 354) should be connected by rubber tubing with 
a tank or bucket of iced water, and the water passed through it by siphon- 
age and allowed to escape into a vessel through another tube attached to 
the opposite end of the coil. The iced water should be renewed each time 
the tank becomes empty for about one hour, or until the pain ceases 
and the purulent discharge becomes more profuse. 

An ice-bag filled with cracked ice may be used for about one hour 
instead of the Leiter coil. The ice should be renewed as often as it 
becomes melted. The bag may be fastened over the mastoid process by 
bands of linen. 

Hot irrigations with bichloride of mercury, 1 to 5000, may be used 
every hour to promote the reaction of inflammation. 

Bier's treatment by constriction of the neck, if judiciously applied, 
often exerts a favorable influence upon the course of the disease. 
The patient should be placed in bed, the foot of which is raised 
several inches from the floor, and an Esmarch elastic band applied 
around the neck. It should produce no pain or discomfort, and only 
slight cyanosis of the face. It should be kept in position about sixteen 
hours of the twenty-four. It should be applied four times daily, with 
two-hour intervals between applications. If the bandage is applied 
tight enough to produce pain, it may do great damage. 

The object of Bier's treatment is to promote the reaction of inflamma- 
tion; that is, to increase the passive hyperemia and the migration of 
leukocytes, so as to remove the bacteria and their toxins. Ice, in view 
of these principles, is contraindicated as it diminishes the reaction of 
inflammation. Inasmuch as the mastoid may be regarded as an en- 
capsulated organ, ice is not always contra-indicated. Encapsulated 
organs sometimes become so distended by inflammatory swelling that 
the flow of blood through them is very much blocked. Ice relieves the 
distention and establishes the flow of blood, and is indicated under the 
circumstances. When the distention or pressure symptoms (excessive 
pain and scanty discharge of pus) are relieved ice should be discontinued 
and measures adopted that promote the reaction of inflammation. 

Other methods of promoting the reaction of inflammation are leeches, 
light, heat, hot poidtices, etc. (See Chapter VII.) Of these, leeching, 
tiie leukodescent light, and Bier's treatment are of special value in the 
treatment of acute mastoiditis. 

Leeching should be more generally used than it is at present, as it is 
one of the best means of promoting the reaction of inflammation. I have 
seen cases following the measles running a temperature of 102° to 104°, 
raj)i(]]y subside after the use of leeches. 

Subacute Mastoiditis. — Tliis form of mastoiditis has been n fernMl 
to under Acute Mu.stoicHtis as the stage following the subsidence of the 



736 ■ THE EAR 

acute symptoms. It should be regarded as a chronic disease, as it only 
responds to treatment suited to chronic cases. While the conditions 
present may be of recent origin, they do not respond to the treatment 
suited for acute cases. The infectious agent is usually the staphylococcus, 
the usual germ in chronic suppuration. 

Subacute mastoiditis is, therefore, the persistent remains of an acute 
mastoiditis, in which the more active microorganisms have disappeared, 
the staphylococcus perpetuating the inflammatory process. It is 
amenable to such treatment as is recommended for Chronic Mastoiditis. 



ACUTE PERIOSTITIS OF THE MASTOID PROCESS; SUBPERIOSTEAL 
MASTOID ABSCESS. 

Subperiosteal mastoid abscess is characterized by a pronounced 
bulging outward of the affected ear. The auricle at its superior 
portion stands far from the side of the head, while its entire free 
border stands well out, almost at right angles to the plane of the side 
of the head. In other words, the outline of the ear, as seen from 
either the front or the rear, falls from the upright toward the horizontal 
plane of the head. 

Upon manipulation the swelling above the auricle fluctuates more or 
less in proportion to the amount of pus beneath the soft tissues. Duplay 
says that before the pus forms externally one feels the elevation and 
depression, under pressure, of the external table of the mastoid. 

The alarm occasioned by an abscess of this type is out of proportion 
to the danger attending it, as it rarely proves fatal. 

Etiology. — It usually has its origin in an infectious otitis media which 
extends to the antrum and mastoid cells. In young children the middle 
ear and antrum alone are involved, as the mastoid cells as not yet formed. 

The periosteum over the squamous portion of the temporal bone is 
more easily separated (Macewen) than over the mastoid process. In 
consequence the pus passes upward and causes the outward bulging 
of the upper portion of the auricle. 

Chronic otitis media suppurativa predisposes to the formation of the 
abscess. A low stage of vitality is also usually present. It usually 
occurs in children, hence the movements of the bony plates. 

Treatment. — In acute cases it is often only necessary to make a free 
incision through the skin and periosteum covering the mastoid process 
and evacuate the purulent accumulation. As the abscess is of otitic 
origin, it may in some cases be necessary to perform a mastoid operation 
either at the time of the incision or subsequently. In chronic sub- 
periosteal abscess the simple incision (Wilde's) may not effect a cure, as 
the ear disease is well established and may require an operation. 



CHRONIC MASTOIDITIS 737 



CHRONIC MASTOIDITIS. 



Symptoms and Diagnosis. — Chronic mastoiditis is not necessarily 
characterized bj any special symptom other than those present in 
chronic suppurative otitis media. Mastoid pain and tenderness are 
often absent. Indeed, all focal symptoms are usually absent. The 
mastoid bone often undergoes an eburnizing sclerosis in the course 
of the disease, the cortex becoming quite dense and the cells replaced 
by the dense bone. It is not unusual to find the mastoid process with 
but a few small cells, while the remainder of the process is as hard 
as ivory. In this case the antrum may be smaller than normal. With 
such dense bony substance on the external aspect of the mastoid process 
acute or pressure symptoms are not present. The cranial aspect of 
the mastoid process does not always undergo the sclerosing process, 
and in these cases mastoid tenderness and swelling may be present. 
Intracranial complications, as sinus thrombosis, meningitis, brain 
abscess, etc., may be the first focal symptoms to develop. A neuralgic 
pain often accompanies the osteosclerosis of the mastoid process. 
Schwartze recommends the removal of a wedge of bone from the 
mastoid process for the relief of the pain of osteosclerosis. 

The inspection of the drumhead and the middle-ear cavity often 
affords useful information as to the diagnosis. The drumhead is usually 
almost or entirely destroyed. Usually the short process and the head 
of the malleus are present, while the handle is gone. The incus is often 
entirely destroyed, though it may be present in the more recent cases. A 
fetid purulent secretion fills the meatus and the middle-ear cavity. 
When this is removed and suction is applied with the Siegle otoscope, 
the secretion may be seen trickling from the attic into the antrum. An 
evidence of mastoid involvement is to be found in the presence of a fetid 
odor after the middle-ear cavity is thoroughly cleansed; that is, the 
foul pus continues to enter the antrum from the inaccessible attic and 
antrum, thus perpetuating the odor. 

Another evidence of chronic mastoiditis is the necrosis and absence of 
the incus. In discussing perforations of the eardrum I pointed out 
the significance of a marginal perforation in the postsuperior quadrant 
of the eardrum and the associated necrosis of the incus, signs of disease 
in the antrum. The increased quantity of purulent secretion is also a 
sign of mastoid involvement, although such an involvement may be 
present with scanty discharge. Indeed, Macewen calls attention to the 
fact that in many cases of mastoid disease the discharge is so slight as to 
escape attention. In some of the cases granulations or polypi are the 
only evidence of mastoid disease. The polyp, when examined with a 
delicate curved probe, may be traced to the attic for its attachment. 
Polypi generally signify bone necrosis. If, after cleansing the antrum of 
all secretions, suction is applied tln-ough the Siegle otoscope, and pus is 
seen to trickle down one of the fragments of the ossicles, attic and antral 
involvement may be safely inferred. Indeed, the presence of persistent 
47 



738 THE EAR 

purulent (liscliai-fre uiicliecked by local treatment is fairly good evidence 
of chrojiic mastoiditis. Macewen also called attention to the fact that 
chronic suppuration of the middle ear extending over a period of two or 
more years was usually attended by necrosis. Neuralgic pains in the 
mastoid region occur in those cases attended by eburnizing osteosclerosis 
of the mastoid process. In those cases in which acute exacerbations occur 
there may be headache, especially at night. The mastoid skin may be 
slightly red, swollen, and hot. The temperature rises one or two degrees 
above normal. The meatus is slightly swollen and hyperemic and 
the postsuperior portion near the eardrum is tense and swollen, or 
distinctly bidging. A cessation or diminution of the discharge is 
attended by pain, and signifies an obstruction to the discharge. 

The course of the disease varies greatly in different cases. In some 
it runs a long and uneventful course without distinct symptoms other 
than the intermittent discharge. In others acute exacerbations occur 
every few weeks or months with the acute symptoms described in 
the preceding paragraphs, whilst in others the discharge is so slight as 
to escape attention unless the attic of the tympanum is explored with a 
probe. Either of these types may develop one or more of the intra- 
cranial complications and become a very serious disease. 

Caries and necrosis of the mastoid process is a frequent result of the 
retention of the purulent secretion. ]Most cases of two or more years' 
duration are thus affected. Such destruction may take place without 
marked symptoms. The insidious progress of the disease makes it a 
formidable process. As IMacewen has so well said, one with a chronic 
otorrhea is hkened unto one with a charge of dynamite in the head: he 
does not know when it will explode. Safety lies in removing the "charge" 
or diseased process. Tuberculous patients are especially subject to caries 
and necrosis, and do not heal so readily after operation. I recall one 
case on whom I performed a radical operation, and it was six weeks be- 
fore I coidd remove her from the hospital. I subsequently did a second- 
ary operation, and it was six weeks before I could remove her to her 
home. At the second operation I applied Thiersch grafts with success, 
the entire cavity now being covered by epidermis. 

In caries and necrosis careful examination will generally develop 
tendertiess upon pressure, as the periosteum is apt to be swollen and 
inflamed. If in such cases the temperature is recorded every four 
hours, it will be found to be raised. In severe cases paralysis of the 
facial nerve may be present. A bony sequestrum sometimes becomes 
separated and may be removed through the meatus. 

Prognosis. — The prognosis varies with the focal centre of the disease, 
the extent of the necrosis, and the presence or absence of intracranial in- 
volvement. ^^^len there is free drainage and only superficial involvement 
of the mucous membrane, the disease is not essentially a serious one. 
When extensive necrosis is present, serious intracranial complications are 
present, and the danger to life is imminent. Chronic sepsis, as evidenced 
by the yellow pasty skin and an increased leukocytosis, while not serious, 
undermines the general health and paves the way for the development of 



CHRONIC MASTOIDITIS 739 

other serious diseases. According to T. Mark Hovell, attacks of partial 
or complete unconsciousness, restlessness, and feverishness are always 
of grave import when occurring in a person suffering from disease of the 
mastoid process. 

Treatment. — ^The local medical treatment of chronic mastoiditis is the 
same as that given for chronic suppurative otitis media (pp. 723 to 727). 
When this has been tried for a few weeks without effecting a cure of 
the disease, the mastoid antrum and cells and the middle ear may be 
opened, as the object of this mode of treatment is to (a) establish free 
drainage, and (b) remove the morbid material. 

General Indications for the Mastoid Operations. — There are prac- 
tically but three general types of mastoid operation now practised: one, 
the simple mastoid operation for acute mastoiditis, wherein only the 
mastoid antrum and cells are opened ; another, the radical mastoid opera- 
tion for subacute and chronic mastoiditis, wherein the mastoid antrum and 
cells and the middle ear are thrown into one large irregular, but freely 
communicating cavity; the other the meatomastoid operation, which may 
sometimes be used instead of the radical operation. The indications 
for the mastoid operations are in general those phenomena present in a 
persistent otorrhea which do not yield to local treatment (including 
the associated nasal and throat diseases) or to operation through the 
external auditory meatus. The more specific indications are as follows : 

1. Persistent tenderness over the mastoid process, with or without 
copious ear discharge. 

2. Persistent ear discharge and polypi. 

3. Fistulous opening into the roof or postsuperior wall of the external 
auditory meatus. 

4. Caries of the attic, as shown by probing or by bone dust in the ear 
washings. 

5. Facial paralysis, 

6. Labyrinthine involvement, as shown by dizziness, nausea, and 
profound deafness. 

7. Chronic ear discharge with neuralgic pain over the mastoid process. 

8. Chronic ear discharge and septicemia. 

9. Intracranial complications and a history of chronic otorrhea. 
These and other signs may indicate the same type of mastoid operation. 

Indeed, in view of the fact that life insurance companies refuse to insure 
persons affected by chronic otorrhea the otorrhea alone may be a 
positive indication for the radical operation. 



CHAPTER XLV. 

PRINCIPLES OF TREATMENT AND GENERAL CONSIDERATIONS 
IN SUPPURATIVE OTITIS MEDIA. 

There are four cardinal principles to be considered in the treat- 
ment of suppurative inflammations of the middle ear and mastoid cells, 
namely: (1) The promotion of the reaction of inflammation to aid Nature 
in combating the host of invading pathogenic microorganisms; (2) the 
establishment of free drainage and the reduction of pressure; (3) the 
removal of the morbid material; and (4) the maintenance of asepsis 
while repair is taking place. 

1. The Promotion of the Reaction of Inflammation. — As shown in 
Chapter \1, on Inflammation, the reaction of inflammation is a benefi- 
cent process, the object of which is to combat the infectious micro- 
organisms. The reaction of inflammation is a threefold process, 
namely: (a) Increased hyperemia, (b) increased nutrition, and (c) in- 
creased leukocytosis of the affected tissues. 

The increased hyperemia floods the cells of the tissues with nutrition 
and thus raises their resistance. The increased migration of leukocytes 
into the tissues provides a fighting force which destroys the pathogenic 
bacteria and disposes of the dead cells of the tissues. As the reaction 
of inflammation is usually inadequate to successfidly and quickly destroy 
the pathogenic bacteria, the therapeutic indications are to adopt 
measures which will increase, or promote, the reaction of inflammation. 
Various modalities may be used for this purpose, some of which are, 
for anatomical and physiological reasons, especially well adapted to the 
treatment of the ear. (See Chapter VII.) 

As stated in the chapter on Inflammation, heat, irrigation with alkaline 
solutions, incisions, leeching, massage, and radiant energy may be used 
to promote the reaction of inflammation. 

Heat has long been used in the treatment of inflammation. Every 
one has observed the increased redness of the skin under its influence. 
The hyperemia thus produced increases the nutrition, and it is now 
believed increases the migration of leukocytes into the tissues. 

There are differences in heat, as there are differences in silk and 
calico. Heat is produced by a wide range of vibrations. Some wave- 
lengths of wide amplitude and slow vibration produce heat of slight 
penetrating power. Other wave-lengths of short amplitude and rapid 
vibration produce heat of high penetrating power. The shorter the 
wave-length and the more rapid the vibrations, the higher the penetrating 
power. Heat from a hot-water bag or low candle-power incandescent 
lamp is of long wave-length and slow vibration, and is of slight pene- 



SUPPURATIVE OTITIS MEDIA 741 

trating power. Heat from a 500 candle-power incandescent lamp is of 
short wave-length and rapid vibration, and is of high penetrating power. 
The therapeutic value of heat is proportionate to its penetrating power. 
In selecting the modality for the application of heat these principles 
should be borne in mind. If the inflammation is superficial, a hot-water 
bottle or a low candle-power (16 to 100) lamp may be used, though a 
higher candle-power lamp will produce better results. If the inflamma- 
tion is deep seated, a high candle-power incandescent lamp (300 to 500 
candle-power) or an arc light should be used (Fig. 19). 

Radiant light as given by the leukodescent lamp (Fig. 19) is a remedy 
of some value in suppurative otitis media. It not only gives off heat of 
high penetrating power, but it gives off rays possessing high degrees of 
chemical activity. The spectrum of the leukodescent lamp is rich in 
the blue violet rays which effect chemical changes in the tissues exposed 
to them. The leukodescent lamp is, therefore, a mechanical device 
furnishing two powerful therapeutic agents, namely, heat with high 
penetrating power, and blue violet rays of chemical activity. I do not 
believe, however, that the leukodescent light is as good a remedy in acute 
suppurative otitis media as incision of the membrana tympani and 
leeching. The progress of the disease is so rapid, and the structures 
of such vital physiological importance, that it is imperative that imme- 
diate improvement be obtained. Incision of the membrana tympani 
and leeching should, therefore, be used in the early stage of acute otitis 
media. 

As the middle ear and mastoid cells are deeply located, heat of high 
penetrating power should be used to promote the reaction of inflamma- 
tion. If the external auditory meatus is utilized, heat of low penetrating 
power, as irrigation with hot sterile or alkaline water, may be used, 
the heat being brought in direct contact with the inflamed tissues 
through the membrana tympani. Clinical experience has shown hot 
irrigations through the auditory meatus to be of considerable value in 
acute catarrhal otitis media (G. P. Head) and in the early stage of 
suppurative otitis media. After the formation of pus and after perfora- 
tion of the membrana tympani it is of comparatively little value. Heat 
should therefore be reserved for the early presuppurative and pre- 
perforative stage of acute suppurative otitis media. 

Irrigation with alkaline solutions but slightly increases the hyperemia 
and leukocytes, and is, therefore, of but little value in the treatment of 
suppurative otitis media. 

Incision, of the inflamed tissue has long been a therapeutic measure 
of acknowledged efficacy. In the treatment of acute catarrhal and pre- 
perforative stage of suppurative otitis media, incision of the membrana 
tympani is one of the most efficient modes of treatment. The good 
effects following incision of the membrana tynij)ani are not altogether 
due to the increased liyf)eremia and leukocytes, though this influence is 
greater tlian is generally believed. In addition to the increased reaction 
of inflammation, the incision of the membrana tym])ani establishes 
free drainage and permits of the removal of the morbid material. 



742 THE EAR 

Incision of the metnhrana tympani is an almost ideal therapeutic 
measure in the early or preperforative stage of acute suppurative otitis 
media, though it is of little value in the later stages of the disease; 
nor has it any considerable value in the chronic type of the disease. In- 
deed, but little can be done by promoting the reaction of inflammation 
in chronic suppurative otitis media. In such cases the establishment 
of free drainage and the total removal of the morbid material should be 
accomplished. The incision of the membrana tympani should be long 
and curved, or V-shaped, to permit the secretions to flow through it. 

Leeching is another old and all but discarded remedy in the treatment 
of acute inflammation. In my hands it has proved one of the most 
satisfactory methods of combating acute catarrhal and suppurative 
otitis media. It is my practice to apply from three to five leeches over 
the mastoid process and one to the tragus in front of the ear. If applied 
in the preperforative stage, or v^'hen the mastoid is swollen and tender, 
or when pain is present, the improvement is usually prompt and marked. 
Indeed, the case often proceeds to rapid resolution. 

Leeching increases the hyperemia and the migration of leukocytes 
into the inflamed tissues, and thus favors the destruction of the patho- 
genic bacteria and the repair of the tissues. 

Artificial leeching is, perhaps, of equal value, and is easier of applica- 
tion. The skin over the mastoid process should be incised, as shown 
in Fig. 370, the circular knife being adjusted with a set screw so as to 
cut the desired depth. When the incision is made the exliaust pump 
should be applied, as shown in Fig. 371, and the air exhausted by turning 
the hand screw. An ounce of blood may thus be drawn from the in- 
flamed tissues. The effect of this procedure is to overcome the venous 
stasis and edema, and thus establish a more rapid arterial flow of blood 
through the tissues. The nutrition of the tissues is raised and the migra- 
tion of leukocytes is increased. 

Massage is of little value in promoting the reaction of inflammation in 
otitis media. External mechanical vibratory massage under the angle 
of the jaw over the course of the Eustachian tube will often quickly 
relieve the edematous obstruction to the Eustachian tube in tubal catarrh. 

In the acute and chronic stages of suppurative otitis media the leuko- 
descent light may be applied with some advantage, though other methods 
of treatment should also be used. 

2. Establishing Free Drainage. — The second principle of treatment, the 
establishment of free drainage, is a very important part of the treatment 
of suppurative otitis media. If free drainage is maintained, infection 
rarely persists, whereas if the drainage is blocked, infection is apt to 
occur, or, if present, to persist. 

In the early stage of acute otitis media free drainage may be established 
by incising the membrana tympani. The Eustachian tube is, for the 
time, inadequate to carry away the excess of secretions. A free incision 
of the membrana tympani, as shown in Fig. 359, affords an accessory 
outlet for the secretions, and, in addition, it promotes the reaction of 
imflammation and relieves the pressure and attending necrosis. 



SUPPURATIVE OTITIS MEDIA 743 

If the obstruction is in the aditus ad antrum, incision of the membrana 
tympani may not estabhsh free drainage; indeed, it may be necessary to 
perform a mastoid operation in order to do it. In some cases of chronic 
otorrhea the obstruction is at the floor of the attic, which is formed by 
the heads of the malleus and incus, together with the ligamentous bands 
and adventitious cicatricial tissue resulting from the inflammatory process. 
In such cases the removal of the malleus and incus would establish free 
drainage. Heath claims that the Eustachian tube is usually adequate to 
drain the tympanic cavity, even when diseased, but that it is inadequate 
to also drain the diseased mastoid antrum and cells. He therefore 
recommends that the secretions from the antrum and mastoid cells be 
diverted from the aditus ad antrum to the external auditory meatus, 
as described in the meatomastoid operation. 

3. Removal of Morbid Material. — Wliatever method of treatment is 
adopted, earnest effort should be made to remove all obstruction to the 
flow of secretions from the tympanic cavity. In infants and children the 
removal of the adenoids may accomplish the purpose by unblocking 
the Eustachian tubes. The removal of aural polypi or granulations 
may temporarily establish drainage. Incision of the membrana tympani, 
leeching, hot irrigations, dry heat, etc., may act favorably in establishing 
drainage. In many cases it will be necessary to resort to a mastoid 
operation. 

4. Maintaining Asepsis. — Having promoted the reaction of inflamma- 
tion, established free drainage and the removal of the pressure, and 
having removed the morbid material from the diseased ear or mastoid 
cells, there remains but little to do to maintain the parts surgically clean. 
Gauze dressings applied to the auditory meatus or to the mastoid wound 
is all that is necessary for this purpose. Extraneous infection is thus 
prevented while the reparative process is in progress. 



THE TREATMENT OF CHRONIC SUPPURATIVE OTITIS MEDIA 
AND MASTOIDITIS. 

The consideration of this subject will not be divided into medicinal 
and surgical treatment, as is usually done, but will be considered accord- 
ing to the predominance of the type and location of the morbid process. 

Suppuration of the atrium (lower chamber of the middle ear), perhaps, 
does not exist alone, but is usually associated with the same type of 
inflammation in the attic, antrum, and mastoid cells. The focal centre of 
the ])rocess may, however, be located in the middle ear, and the case can 
be successfully treated via the auditory meatus. 

The dry (jauze treatment should be carried out as described under 
Acute Suppuration of the Atrium. In chronic cases the perforation in 
the dninihead is usually quite large, sometimes involving the entire 
membrane. It is not, therefore, usually necessary to enlarge the ])er- 
foratioii or incise the drumhead. The gauze wick should be infrodiiccd 
into the cavity of the middle ear, and the moatus loosely packed with 



744 THE EAR 

it. It is usually sufficient to apply the gauze every alternate day, 
altliou»li it may he necessary to do it oftener. 

The Alcohol Treatment. — This does not differ materially from that 
already given under Acute Suppuration of the Atrium (p. 715). 
It should be preceded, however, by thoroughly cleansing the secretions 
from the meatus by cotton-wound applicators and by inflation of the 
middle ear with the Eustachian catheter. 

The alcohol should be left in the middle ear for from five to twenty 
minutes, the patient inclining the head to one side. The alcohol should 
vary in strength (25 to 95 per cent.) according to the pain produced by 
its introduction. Some cases tolerate the 95 per cent, solution from the 
start, while others will complain of pain if a greater strength than 25 per 
cent, is used. In such cases begin with the weaker solution, and then 
instil a stronger and still stronger until the full strength solution is 
tolerated. 

In the interims between treatments the ear may be left without special 
protection other than a loose piece of absorbent cotton or sterilized gauze 
in the external meatus. 

The treatments may be repeated on alternate days, or as often as 
indicated. 

Some writers advocate the addition of boric acid to the alcohol, while 
others use an etheric-alcohol solution of iodoform. 

Alcohol acts as a hygroscopic agent, thereby depleting the edematous 
membrane and granidation tissue. It is an antiseptic and astringent, 
and it excites the reaction of inflammation. 

The Compound Tincture of Benzoin. — During the last ten years I have 
used the compound tincture of benzoin in nearly every case of otorrhea 
coming under my care. It has steadily grown in my estimation with 
each passing year. Its efficacy is in part due to the alcohol in its com- 
position, but not altogether to it. It is more soothing than plain alcohol, 
and it is more antiseptic and more healing. I have found it to be of 
special value in those cases in which the fetid odor is present. This 
speedily disappears and the other features of the case also improve. 

The compound tincture of benzoin should be dropped into the meatus, 
the head being inclined toward the opposite side. If the discharge is not 
too profuse the gauze may be allowed to remain in the ear and meatus 
for two or three days without developing fetor. 

The middle ear should be previously cleansed as described above, 
although this may not be necessary after a few applications of the 
remedy, as the discharge often rapidly decreases until there is scarcely 
a drop on the gauze when removed. 

I do not wish to be understood as claiming that the otorrhea will not 
return after the discontinuance of the benzoin, for I believe it will in 
most cases, no matter what form of local treatment is pursued. 

Irrigation. — The use of the syringe is not indicated, as it is in acute 
cases. It may be used to advantage, however, when there is a consider- 
able accumulation of desiccated or tenacious mucous and pus in the 
atrium of the middle ear. The force of the stream loosens and propels 



SUPPURATIVE OTITIS MEDIA AND MASTOIDITIS 745 

the secretions from the middle ear, and thus prepares the tissues for 
treatment by other methods. Sterile water or normal salt solution 
should be used as hot as can be comfortably borne by the patient, 
one-half gallon being the correct amount for each treatment. 

The Boric Acid Treatment. — This method of treatment is of less value 
in chronic than in the acute inflammations of the middle ear. If the 
discharge is profuse it may be used, although other measures afford more 
relief. 

Camphoroccol has recently been highly recommended by Hotz and 
others in obstinate otorrhea in which other methods of treatment had 
failed. Hotz reports several cases in which the remedy seemed to 
give speedy and satisfactory relief. Further observations along this 
line are needed, however, before the real value of this remedy can be 
estimated. 



THE TREATMENT OF SUPPURATION INVOLVING THE ATRIUM 
AND ATTIC. 

Under this caption are included those cases in which the centre chiefly 
involved, or which forms the chief source of annoyance and danger, is 
the attic. The consideration of the best methods of treatment will, 
therefore, hinge upon the structure and arrangement of the parts com- 
posing the attic. 

The point of chief interest is the lower boundary or floor of the attic, 
namely, the heads of the malleus and incus, and the ligaments and ad- 
ventitious fibrous bands uniting them to the walls of the tympanum. 
Another point of clinical interest is Shrapnell's membrane, or the mem- 
brana flaccida. Perforation of this membrane affords one of the most 
obvious signs of attic suppuration. Irrigation of the attic may be 
accomplished with a curved cannula inserted through the perforation in 
Shrapnell's membrane (Fig. 382), and local medication and explora- 
tions may be carried on through it. 

The floor of the attic is of importance because, whereas in health it 
affords ample drainage for the secretions, it is oftentimes inadequate 
in chronic otorrhea. The inadequacy may be due to the excessive and 
heavy secretions, or to a more or less complete obstruction by the adven- 
titious fibrous tissue of the spaces in the floor of the attic. At any rate 
the secretions are pent up in the attic and may give rise to serious path- 
ological changes. 

While the principles of treatment remain the same, the motive for 
treatment increases tenfold. 

Free drainage is imperative and should be established by surgical 
interference. The perforation may be enlarged by an incision extending 
anteriorly and posteriorly. I^lie treatment should be addressed not 
alone to the attic, but to tlie atrium also. In other words, the treatment 
described in tlie preceding section should l)e used, mid in nddilion 
thereto the follovvinfj measures should be instituted: 



746 THE EAR 



THE TREATMENT OF SUPPURATION OF THE MIDDLE EAR 
AND MASTOID PROCESS. 

Treatment of Suppuration of the Atrium.— Although it cannot be 
correctly said that infection is ever limited to the atrium (lower cham- 
l)er of the middle ear), it is nevertheless expedient to treat some cases as 
though they were thus restricted. They are probably only mildly in- 
fectetl, and in reality involve the whole tympanum (atrium and attic and 
mastoid spaces). But as the area of infection is limited, simple meas- 
ures often suffice to effect a cure.- While the whole tympanum and mas- 
toid spaces may be somewhat involved, the focal centre of infection is in 
the atrium, or lower chamber of the middle ear. As this chamber is 
easily accessible through the external auditory meatus and through the 
Eustachian tube, the four principles of treatment (p. 740) may be 
effectively carried out. 

In acute cases the perforation is usually small, and should be enlarged 
by free incision of the drumhead (Fig. 373). An unwarranted dread 
or fear exists among a large percentage of those practising medicine as 
to paracentesis or incision of the drumhead. Such fear is ill-founded, as 
experience has shown that such injuries are quickly repaired without the 
intervention of the one causing it. Indeed, the wound usually closes 
too quickly. However this may be, the first cardinal principle is to 
establish free drainage as quickly as possible. This can be done most 
easily by enlarging the already existing perforation. The incision 
should be curvilinear, so as to create a flap of the membrane on one side 
of the perforation (Fig. 373). The pus escapes through an opening as 
large as the perforation plus the space occupied by the flap. Through 
this opening the atrium can be freed from morbid material and kept 
aseptic by gauze drainage. Having thus established (a) free drainage, 
(6) asepsis, (c) freedom from morbid material, and the reactions of 
inflammation, resolution may be expected. The difficulty in most 
cases treated is that the attending physician does not make it possible 
to accomplish the four cardinal principles of treatment. He trusts to 
hydrozone, boric acid solutions or powder, alcohol, and other remedies 
to do what they cannot, except free drainage is first established. 

Method of Incising the Drumhead. — (a) First, remember that the 
drumhead is within 3 to 4 mm. of the inner tympanic or labyrinthine wall. 
It is important, therefore, that the knife used should not penetrate the 
drumhead deeper than 1 to 2 mm., as the inner wall may be injured 
thereby. There could be no special harm in incising the mucous mem- 
brane of the inner wall, but the oval and round windows are located 
there, and to disturb their contents would expose the labyrinth to the 
dangers of infection. This is mentioned because the knowledge of it will 
prevent careless or reckless incisions of the drumhead. I will say, how- 
ever, that such accidents rarely occur, even at the hands of an inexperi- 
enced surgeon. 

(t) The best instrument for the purpose is Hartman's curved bistoury 



SUPPURATION OF MIDDLE EAR AND MASTOID PROCESS 747 

(Fig. 355). It is pointed and the cutting edge is concave, thus favor- 
ing the retention of the blade within the membrane as the incision is 
made. If it were convex on its cutting surface, it would have a tendency 
to shde out of the membrane as the incision is made. 

Paracentesis (simple puncture) should not be practised, as the opening 
thus made is entirely inadequate for the purposes heretofore described 
under Principles of Treatment. 

(c) The incisions should begin at the centre (regarding the existing 
perforation as the centre), and should radiate in the direction affording 
the largest field of drum membrane. The flap thus formed between 
these radiating incisions will be somewhat triangular in shape, with the 
apex toward the perforation and the base (usually) toward the periphery 
of the drumhead. 

(d) Where it is not easy or feasible to make the incisions as described 
above, it should be done as follows: Select the largest available field of 
the drumhead and begin the incision near the periphery, and extend it in 
a curve or crescentic line toward the opposite side of the chosen field. 
The curved or crescentic incision allows the flap to open out as a valve 
and permits free drainage and cleansing of the atrium. 

The Removal of the Morbid Material. — ^Having made an opening in the 
drumhead sufficiently large to allow free drainage, the next step is to 
remove the morbid material. This is accomplished in a variety of ways, 
among them being the use of the syringe. 

The use of the syringe in otitis media has been so much abused, or, 
rather, the patient has been so much abused by its use, that I hesitate to 
recommend it. I shall do so only with specific directions as to how it 
should be used. When so used, it is, under proper circumstances, a 
very valuable mode of treatment. 

How to Use the Ear Syringe. — (a) Select a syringe that is aseptic 
and that will throw a fair-sized steady stream. Dr. Todd has devised 
one that meets these requirements. It is operated by means of a bulb, 
and is so constructed that it can easily be rendered aseptic. Nearly all 
the ear syringes on the market are hotbeds of microbic propagation, and 
their use in the middle ear is attended by considerable risk. 

(6) Use large quantities of sterile (boiled) water or other fluid. It 
is the quantity I wish to emphasize, rather than the kind of solution 
used. A little water or aqueous solution of some antiseptic material 
may be very harmful in such cases. If one begins to "wash" a septic 
mucous membrane, it should be very thoroughly done. Experience has 
taught us that only by using large quantities of solution can good results 
be ol)tained in otorrhea. Small, meagre flushings often aggravate the 
condition. 

(c) After quantity I will name temperature as the element of next 
importance in syringing the middle ear. The solution should be slightly 
above blood heat, 105° being best suited for the purpose. The tem- 
perature should be subject to variation, however, according to the 
syringe used. If a fountain syringe is used, the solution will cool sev- 
eral degrees in passing through the long tube. The solution should be 



748 THE EAR 

so tempered that when it reaches the ear it is about the temperature of the 
blood, or a httle aljove rather than below it. 

id) The solution used may be what is known as the "normal salt solu- 
tion." A formula which is correct enough for the purpose is: One 
teaspoonful of table salt to each quart of water. Warm boric acid 
(saturated) solution is a favorite remedy with some, while others prefer 
bichloride of mercury (1 to 5000 or 1 to 2000). 

Still other solutions may be used (as carbolic acid), although it is 
doubtful if any of the antiseptic solutions excel the normal salt solution. 
The chief value of the procedure, as I view it, is to "w'ash" the infected 
membrane. Plain water is known to irritate mucous membranes, hence 
the addition of the salt l)rings it to about the specific gravity and 
alkalinity of the blood, thereby overcoming the irritating quality of the 
water. 

The antiseptics as used really exert no microbe-killing or inhibiting 
power other than that due to the removal of the "soil" in which the 
microbes are embedded. 

(e) The frequency with which these flushings may be used will depend 
upon the quantity of the discharge and the virulency of the infection. 
If after cleansing the ear in this way (with the other treatments, as 
described) the ear remains comparatively free from morbid material for 
twenty-four to forty-eight hours, there is no occasion for using it 
sooner. The frequency will, therefore, depend upon the length of 
time the ear remains "clean." E the discharge forms rapidly, it may 
be necessary to use the douche oftener. 

(/) After having thoroughly syringed the ear, the moisture should be 
removed by the use of a cotton-wound probe. In some cases, alcohol 
(50 to 95 per cent, strength) may be used with advantage for its hygro- 
scopic property. Its affinity for water is so great that it will abstract it 
from the swollen and edematous tissue. I have found it to be irritating 
in some cases, especially those very acutely inflamed. It should, there- 
fore, be used in weak solution, or not at all, in acute cases. 

{g) The middle-ear cavity and external meatus should now be loosely 
packed with sterile gauze, wdiich acts as a wick, removing the secretions 
as fast as they are formed. Amberg has had gauze strips one-half an 
inch wide and six inches long put up in oiled paper and sealed pack- 
ages for this purpose. The idea is an excellent one, as the strip is 
handled only at the time of its use. 

(Ji) If the discharge is very profuse, a pad of gauze should be placed 
in the concha and held in place by a collodion dressing (Fig. 420). 

[i) The hands, instruments, etc., should be cleaned as for an opera- 
tion, as otherwise infection may he added to that already existing. 

The Dry Gauze Treatment. — Spencer first advocated the use of dry 
gauze in the treatment of middle-ear suppuration in 1880-82. Since 
then Gradinego and Pierce have, advocated its use. The special points 
in its use may be tabulated as follows : 

(a) First, remove all the secretions from the middle ear and meatus 
with cotton-wound probes. (It is here presumed that if the perforation 



SUPPURATION OF MIDDLE EAR AND MASTOID PROCESS 749 

in the drumhead is not large enough to allow free drainage, it has 
been incised, as heretofore described.) The parts may be also treated 
by instillations of alcohol in 50 to 95 per cent, aqueous solution. This, 
in turn, should be wiped out. Alcohol not only acts as a hygroscopic 
agent, but is astringent and antiseptic as well. 

(b) The meatus should be loosely packed with a strip of gauze about 
one-half inch wide and three inches long. For this purpose a small silver 
probe, with two notches filed at right angles across its end (Fig. 318), as 
suggested by Bane, should be used. The notches form four shallow 
teeth, which catch in the meshes of the gauze and carry it to the desired 
location. The end of the strip should be placed against the opening in 
the membrana tympani, so that the secretions will be taken up at once 
and carried outward through the gauze in the meatus. 

The gauze may be covered with a small piece of absorbent cotton and 
sealed with an ether solution of collodion (Fig. 420). 

(c) The dressing should be left in position for from twelve to seventy- 
two hours, according to the amount of discharge. It should then be 
removed and the same procedure repeated until improvement or 
complete relief is afforded. Not every case will yield to this mode of 
treatment, nevertheless many will do so. 

The Alcohol Treatment. — This mode of treatment also has its advo- 
cates, and for good reasons. I recall an incident which gave me great 
confidence in its efficacy. At that time I had 10 cases of chronic otor- 
rhea under my care, all of which were being treated by the dry gauze 
method. Improvement was slow, and I determined to change to the 
alcohol treatment. In about one week the otorrhea ceased in eight cases. 
Subsequent experience has not upheld the good opinion formed at this 
time. Nevertheless, this mode of treatment is a good adjunct to the dry 
gauze treatment. 

Many acute cases do not tolerate alcohol well, violent pain and inflam- 
matory edema often being excited by its use. 

Boric Acid Powder Treatment. — This mode of treatment is quite old, 
and therefore merits attention. The fact that it has remained in use 
so long argues that there is probably some merit in it. It is true that 
remecUes are now used in its stead which give better results. The 
question arises, however, as to whether the improved results are due so 
much to the newer remedies as to the manner in which they are used. 
The })oric acid powder treatment fell into disuse about the time modern 
surgery was adopted l)y the profession. Hence, the newer remedies have 
l)ecn used with antiseptic and aseptic precautions. For example, so 
mucli care was not formerly exercised to thoroughly drain and clear the 
middle-ear cavity of morbid material, nor was it attempted to render it 
aseptic. The superficial pus and debris were removed anfl the lioric acid 
powder (usually a very impure preparation) was poured into the exter- 
nal meatus and packed tightly. Hence, I believe boric acid fell into 
disrepute as a remedv in otorrhea, not becnusc it is an iiiefncicuf nMuedy, 
but because it was used in an ini|)i-()])(-i- niainici- oi' niidci- iinpi'ojx'i' con- 
ditions. 



750 THE EAR 

Boric acid should l)e used as follows: 

(a) Secure a chemically pure boric acid powder (Merck's) or flour. 
The impure preparations contain the biborate of soda, which cakes in 
the ear and causes obstruction to the drainage. It is also acid, and irri- 
tates the mucosa. Pure boric acid is neutral, and will not "cake" or 
irritate the tissues. 

(6) The best way to use it is with a powder blower (Fig. 21). The 
powder shoidd be blown into the external meatus and middle ear with 
low air pressure. If a high pressure is used the whirlwind created in 
the meatus will blow the powder out again. In this way a thin layer 
of powder is introduced into the diseased ear, where it acts as an 
absorbent and antiseptic. It dissolves slowly, and its action is pro- 
longed for some time. It will not "clog" or obstruct the drainage. 

(c) The meatus should be loosely packed with a strip of gauze. 

(d) The treatments should be repeated as often as the powder becomes 
wet with the secretion. 

(e) Previous to introducing the powdered boric acid, the middle ear 
and meatus should be cleansed with cotton mops. 

(/) This treatment is especially useful in those cases in which there is a 
profuse acrid discharge and the perforation is large. 

Eczema and dermatitis of the external auditory canal and auricle are 
often present in otorrhea. They are due to the irritation of the aural 
discharge. The application of the following ointment has proved very 
satisfactory: 

I^ — Zinc oxide 3i 

Morphine acetate gr. j 

Lanolin, 

Vaseline aa q. s. ad 5J- — ^I- 

Ft. unguent. 
Sig. — Appb' once or twice daily to the inflamed auricle and meatus with a cotton-wound probe 
or applicator. 

The alcohol treatment is not well tolerated by these cases, the boric 
acid and gauze treatments being better. 

Pain in the ear should cause the attending physician to carefully in- 
vestigate its cause. It may be due to insufficient drainage through the 
perforated drumhead, in which event it should be incised as heretofore 
described; or it may be due to an obstruction (Sheppard) in the 
aditus ad antrum. The mucosa may be swollen in the canal, or granu- 
lations may have formed and occluded its lumen. This would interfere 
with the discharge of the pus from the antrum and mastoid cells into the 
attic of the ear. The pain is the expression of retention pressure, and 
steps should be instituted to unblock the occluded passages. As I have 
already pointed out, the obstruction is probably in the aditus ad antrum, 
the floor of the attic, or in the drumhead. If the floor of the attic is the 
seat of the obstruction, it may become necessary to remove the malleus 
and incus. Sheppard reports his results in 31 cases, and finds that 
the removal of the malleus alone is not usually followed by good results. 
(See Ossiculectomy.) If the obstruction is at the drumhead, it will bulge 
outward, the perforation being either small or blocked with granulations. 
The drumhead should be incised and the granulation tissue removed. 



SUPPURATION OF MIDDLE EAR AND MASTOID PROCESS 751 



To remove the granulations it may be necessary to enlarge the perfora- 
tion in the drumhead by incisions radiating from the perforation. 
Through this opening the granulations can be still further examined and 
removed, either with a snare (Fig. 379) or with a small spoon curette. 
Local anesthesia may be induced with cocaine (10 to 20 per cent.), or with 
the following mixture : 

I^ — Cocaine crystals, 

Carbolic acid crystals, 

Menthol crystals . aa oj — M. 

Mix by rubbing in a mortar, and a syrupy fluid is formed. 



The above solution, when dropped into the meatus, will produce local 
anesthesia when cocaine fails to do so. 




Showing the removal of an aural polyp which projects into the meatus through a 
perforation in the membrana tympani. 

If the ohstruction is in the aditus the problem becomes at once more 
difficult and serious. It is practically impossible to reach the canal 
tlirough the external auditory meatus without resorting to a mastoid 
operation. If the malleus and incus are removed, the obstruction may 
gradually disappear without the mastoid operation. The advantage to 
be gained by doing the mastoid operation is that the disintegration which 
occurs with such rapicHty under retention pressure is checketl before 
serious and extended destruction of the tissue takes place, and the (hinger 
of meningeal and cranial involvement is thereby reduced to the miniinum. 

If the pa'ni is associated with hnlginr/ and redness of the ])ostsiiperior 
wall of the meatus near the drumliead, the in(Hcations for immediate 
operation are imperative. If the bulging and re(hiess are not ])resent, 
other treatment may be tried. In the meantime close observation of 
the case should be maintained. A ra])id rise in t(Mnp(M-ature, with chills 
or chilliness and prf)fnse sweating, slrongly iiidicaUvs se])(ic poisoning, 
possibly from sinus thrombosis. 



CHAPTER XLVL 

THE GENERAL PATHOLOGY OF OTITIS MEDIA AND 
MASTOIDITIS. 

Microorganisms are the exciting causes of middle ear and intracranial 
pyogenic processes. Various organisms are active, either alone or in 
combination, no special one being characteristic of these processes. 

The free communication between the epipharynx and middle ear 
and the perforated drumhead makes infection easy if the local con- 
ditions are favorable. The vitality is lowered during the course of one 
of the exanthematous fevers, hence the conditions for infection of the 
middle ear are favorable. Pathological destruction and changes occur 
in the mucosa and drumhead, and microorganisms continue to flourish, 
the suppurative process being established. The cilia wdiich normally 
partially cover the tympanic mucosa are destroyed, or their vitality is 
so impaired that their propelling function is no longer adequate to drive 
the secretions toward the Eustachian outlet. Accumulation, decompo- 
sition, and irritation follow. The mucosa breaks down, the periosteum 
covering the bone beneath loses its vitality and disintegrates, and the 
bone depending upon it for nutrition becomes necrotic. The arteries 
in the mucosa become thrombosed, and the arterial supply is thus cut 
off from the membrane and periosteum as well as from the bone. Thus 
the process of disintegration proceeds with greater or less activity, often- 
times without serious symptoms being present. The brain may be ex- 
posed by the caries of the tegmen tympani or through the various chan- 
nels of communication. Finally, the conditions become such that acute 
reaction sets in, and life is placed in imminent danger. 

It has been said that about two years of chronic suppuration usually 
precedes bone necrosis in the middle ear and its accessory cavities. This 
should be taken only as an approximate estimate, as the time varies with 
the type of the infection which predominates, and with the obstruction 
offered to the discharge of the morbid secretions. If the flow from 
the mastoid cells and antrum is free and unobstructed, the process 
may continue for years without l)ony necrosis. If, on the other hand, 
marked obstruction occurs quite early in the suppurative process, bone 
necrosis may take place before the two years have elapsed. 

It is of great importance in estimating the gravity of a suppurative 
process in the tympanum to determine definitely the predominant char- 
acter of the microbic infection that is present. To this end cultures and 
microscopic examinations should be made. While but few physicians 
are prepared to make either the cultures or microscopic examinations, 
nearly all know where they can secure culture tubes and have such 



GENERAL PATHOLOGY OF OTITIS MEDIA AND MASTOIDITIS 753 

examinations made. The attending surgeon should smear the secre- 
tion from the ear on the contents of the cuUure tube and send it to a 
pathologist. 

I will here suggest a few places where the above examinations may be 
made: 

(a) The Health Board of your own or some neighboring city. 

(b) A brother practitioner. 

(c) The nearest medical college, or the one from which you grad- 
uated. 

{d) A pathological laboratory established for the purpose of accom- 
modating those in need of such work. 

The expense of such an examination is small, and the information 
obtained may be of inestimable value to the patient. 

John Funke has reported the results of his observations as to the 
"Bacteriology of Otitis Media," and his work seems so conclusive and 
suggestive that an epitome of it is herewith given: 

"The following conclusions are based on a study of the literature of 
otitis media and my observations: 

"1. There is no specific organism of otitis media. 

"2. Acute otitis media is not invariably monomicrobic, as is com- 
monly held. The pathogenic organism present may be of a single 
variety, but with it are frequently found a varying number of associated 
bacteria, which may or may not be influential in determining the outcome 
of the case. 

"3. The organisms commonly found, in the order of frequency, are: 
The pneumococcus, streptococcus, pyogenic staphylococci (albus and 
aureus), and the bacillus of Friedlander. I am strongly inclined toward 
the belief in a definite grippal otitis, primarily due to the influenza bacil- 
lus, which, however, becomes quickly associated with, or replaced by, 
other organisms. 

"4. The Bacillus diphtherise is more commonly present in otorrhea 
than is usually believed; it may be (a) the initial infecting agent, (6) or 
it may enter with the streptococcus or pneumococcus, or (c) it may be a 
secondary infection carried to the already infected ear by the fingers of 
the patient, or otherwise, as held by Baginsky. 

"5. It is reasonable to believe, as my observations show, that it per- 
sists for a varying period of time in the discharges, and may constitute a 
centre of danger, just as has been thoroughly established concerning its 
prolonged resiflence in the nasal cavities, pharynx, etc. Its frequent 
association with the Bacillus pseudodiphtherire has here the same sig- 
nificance as elsewhere, a factor not as yet fully determined. 

"6. The streptococcal infections are more grave and persist longer 
tlian pure pneumococcal infections, but both arc usually supplanted by 
tlie staphylococcal sooner or later. 

"7. There is a true pneumobacillary otitis, usually acute and quickly 
converted into a mixed infection. The gravity of the process depends 
ahnost cxchisivcly ii])()ii the ehiiraetcr of tlic mixed or s(>con(lary infec- 
tion. 

48 



754 THE EAR 

"8. Chronic suppurative otitis media is practically always a sequence 
of the acute. 

"9. Like the acute, it possesses no specific organism. 

" 10. Unlike the acute, it is practically always polymicrobic. 

"11. Its polymicrobic character may be evinced in any of three ways: 
(a) A mixed infection of pathogenic organisms; (6) one or more recog- 
nized pathogenic organism (usually pyogenic staphylococci), with one 
or more bacteria usually regarded as saprophytes; (c) the usual pyo- 
genic and pathogenic bacteria are absent, and the discharges are main- 
tained through the activity of organisms that commonly lead a sapro- 
phytic existence. 

"12. While anaerobic organisms may play an important part in the 
pathogenesis of chronic suppurative otitis media, my observations have 
not established their almost constant presence, as maintained by Rist. 

"13. The fetor met in the cases here reported can be explained by 
the presence of Bacillus pyogenes fetidus without anaerobic organisms. 

" 14. All clinical and collated bacteriological data indicate that otitic 
inflammations present different bacteriological findings in different 
localities. According to INIoos, during the influenza epidemic of 1S90 
in Vienna the otitic complications were due to the pneumococcus (Weich- 
selbaum), and to the streptococcus in Strasburg, Greifswald, and 
Bonn (Ribbert). 

"15. Reports gathered from literature establish the existence of a 
primary tuberculous otitis, but all observers are of one mind as to the 
almost utter impossibility of the routine demonstration of the bacillus in 
discharge. 

" 16. For the demonstration of the tubercle Ijacillus in suspected cases 
I would recommend an examination of tissue obtained by the curette." 

Gradle and others, some years ago, called attention to the odor attend- 
ing chronic otorrhea, claiming its presence or absence was the "most 
sensitive criterion of the efficacy of the treatment." He says: 

"So long as the pus of the otorrhea smells fetid the treatment em- 
ployed has exerted no curative influence on the disease; and, conversely, 

"The first sign from any treatment of curative influence upon the 
course of an otorrhea is its effect upon the odor of the discharges." 

Macewen says: "The virulence of a discharge cannot be measured by 
its odor. Nearly odorless otorrhea may contain pathogenic micrococci, 
and some of the most serious intracranial inflammatory lesions ensue 
in the presence of odorless otitis media. It is w^ell, therefore, in esti- 
mating the gravity of an otorrhea that pus from the middle ear should 
be stained and examined microscopically and by cultivations." 

He goes on to state that intracranial complications do often arise in the 
course of fetid otorrhea, but that the pathogenic germ is not the one caus- 
ing the odor, it usually being a non-pathogenic microorganism. 

These views, while they seem to be diametrically opposed to each 
other, are really not so opposite as they appear. The first is fallacious, 
in that it leads to the inference that with the disappearance of the odor 
the patient's condition becomes safe; whereas, the second view tefls us 



fil 



GENERAL PATHOLOGY OF OTITIS MEDIA AND MASTOIDITIS 756 

the absence of fetor is no criterion as to the non-virulence of the infection. 
Gradle's views lead, by inference, to the conclusion that absence of fetor 
is a guide to the mildness of the infection; whereas, Macewen says the 
absence of fetor gives no information whatever as to the virulence of the 
infection. He goes still farther and says some of the most virulent intra- 
cranial infections have occurred in connection with odorless otorrhea. 

The author is inclined to agree with Macewen on this point, although 
he readily admits Gradle's major proposition, that the disappearance of 
the odor under the syringe, etc., usually heralds an improved drainage 
and ventilation. The improvement, however, is not due to the removal 
of the odor or the germs producing it, but to the removal of the sapro- 
phytic bacteria and the establishment of free drainage by the removal of 
the desiccated secretions. The disappearance of the odor is incidental, 
and signifies that other and more virulent organisms may have been 
removed also. 

When the true nature of chronic otorrhea is explained to patients, 
many of them reply that they have had the discharge off and on for many 
years with no untoward result, and that they do not fear serious compli- 
cations in the future. They express a belief that is often too prevalent 
among physicians, namely, that chronicity of otorrhea is a guarantee of 
its innocent nature. The process of disintegration has been going on, 
and may continue to do so, so long as the otorrhea lasts. Fresh in- 
vasions of germs, or the encroachment upon a new area, or a lowered 
vitality of the patient, may give rise to sudden and alarming symptoms. 

It may be said that the more chronic the otorrhea the greater the danger 
of intracranial or other extension of the infective process. 

Acute primary otitis media suppurativa rarely extends to the brain or 
meninges, as the process does not continue long enough to break down 
the mucous membrane, bone, and other tissues enveloping it. 

In infants this protection is not so complete, as the various parts of 
the temporal bone are not yet united by ossification. The vascular and 
cartilaginous lines of union afford less resistance to the transmission of 
microorganisms to the cranial cavity; hence, intracranial involvement is 
more common in infants in the course of, or subsequent to, an acute 
primary suppurative otitis media. 

In addition to the infection and consequent ulceration, thrombosis, 
and necrosis, there are other pathological conditions which are inci- 
dental to the suppurative process. Adhesive bands often form in the 
course of this disease, and the ossicles become bound to each other and 
to the tympanic walls. The handle of the malleus, ])eing retracted, may 
become adherent to the promontory. 

The writer has a case under ol)servation, aged forty years, with adhc>- 
sion of the handle of the malleus to the promontoiy. When a young 
child she had sup])uration of the middle ear, following scarlet fever. 
There have been occasional (hscliarges since then. When she came 
under my observjilion llici-c \v:is ;i jirrfordl/oii of Shra jiiicirs nu'iiihraiti'. 
This healed under iipplicnlions of llic nili^lc of silver. I"A;iinin;i(i()n 
with Siegle's otoscope shows the injillens lo be adhereiil (o the pi-onion- 



756 THE EAR 

tory. The anterior half of the drumhead is also adherent in places, 
while the posterior half is perfectly free. In other cases the adhesions 
have been severed (Fig. 373), with great improvement of the hearing. 

Calcareous salts may be deposited in the drumhead and in the tympanic 
mucosa. The articulations of the ossicles may become ankylosed. The 
foot plate of the stapes is sometimes ankylosed from the deposit of lime 
salts in the fibrous ring which unites it to the margin of the oval window 
(fenestra of vestibule). This condition may be mistaken for hyperostosis 
of the bony capsule of the labyrinth (spongifying) , though in the latter 
condition the drumhead and Eustachian tube are normal, whereas in the 
former they are abnormal. 

Granulations (aural polypi) are common, especially in old cases, in 
which the mucosa and periosteum are ulcerated and bony necrosis is 
present. They are the expression of Nature's effort to repair the tissues. 

Middle-ear Suppuration. — Microscopic Examination of One Hundred 
Cases, with Special Reference to the Presence of Tubercle Bacilli and Acid- 
fast Bacilli. — Wyatt Wingrave^ gives the following analysis: Special care 
was taken in obtaining the discharge. Carbol-fuchsin was used in 
staining, with methylene blue as a counterstain: 

Cases. 

Squamous and pus cells present together in 41 

Pus alone 38 

Squamous alone . . .' 21 

Bacteria. 

Staphylococci 41 

Diplococci 20 

Streptococci 7 

Bacillus proteus vulgaris 14 

Micrococcus tetragenus . 4 

Bacillus coli 3 

Gonococci 33 

Bacillus subtilis 2 

Aspergillus niger 1 

Leptothrix 1 

Diphtheria (Klebs-Loeffler) 1 

Yeast 1 

' Jour. Laryngol., Rhinol., and Otol., March, 1903 



CHAPTEE XLVIL 

INTRACRANIAL AND JUGULAR PYOGENIC DISEASES OF 
OTITIC ORIGIN. 

General Considerations.— Infection and inflammation of the middle 
ear, mastoid cells, and labyrinth are not per se usually a serious menace 
to life. The real danger is in the extension of the infection to the con- 
tents of the cranium or to the jugular vein, and thence to the important 
viscera, or a general dissemination throughout the body (general septi- 
cemia). In more rare instances the infection may be conveyed to the dis- 
tant viscera, as the lungs, spleen, liver, heart, and kidneys. Pneumonia, 
splenitis, hepatitis, endocarditis, and nephritis of otitic origin have been 
observed. The infection more often extends to the intracranial sinuses 
(veins) and to the jugular vein. Septicemia is also an occasional sequel 
of otitic and mastoid infection. 

Of the intracranial pyogenic infections, thrombosis of the sigmoid por- 
tion of the lateral sinus, and the various types of meningitis, are most 
often observed. As the symptoms are not always characteristic of the 
type and field of invasion, the differential diagnosis is often difficult to 
make. There are, however, certain general characteristic phenomena, 
especially after the process is well advanced, which usually enable the 
aural surgeon to diagnosticate the condition present. When, for example, 
there is a chill, followed by a rapid and excessive rise of temperature, 
the evidence is conclusive that the system has been invaded by a nu- 
merous pyogenic host from some source. The most probable soinre of 
such an invasion is a disintegrating thrombus. The thrombus, being 
infected, finally undergoes disintegration, and the pathogenic bacteria 
are thrown in great numbers into the general circulation. As the sig- 
moid portion of the lateral sinus is in intimate anatomical relation to 
the mastoid process, the natural inference to be drawn from the chill 
and rapid rise of temperature is that lateral sinus thrombosis is pres- 
ent. If after the lapse of twenty-four hours a similar symptom com- 
plex recurs the diagnosis may be more surely made. Tlie thrombus 
may, however, be in either the superior or the inferior petrosal sinuses, 
longitudinal, or the cavernous sinus. These sinuses are, however, 
usually involved secondarily to the lateral sinus. The symptoms of 
cavernous thrombosis are so characteristic, that, when involved, <hc 
diagnosis is easily made. 

Dift'used purulent meningitis also presents certain characteristic 
symptoms which render the diagnosis com])aratively easy. The tem- 
perature remains more or less constantly elevated, whereas in llnoinliosis 
there are distinct chills followed l)v a sudden and marked rise in I he 



758 THE EAR 

temperature, and a recession to nearly normal within six to ten hours. 
Extradural abscess and brain abscess may be attended l)y only a mod- 
erate, or no elevation of temperature, though there are frequent excep- 
tions to tliis rule. 

Lumbar Puncture. — Lumbar puncture for the diagnosis of menin- 
gitis should be made between the third and fourth lumbar vertebrae. 
A tapeline or cord passing around the body on a level with the crest 
of the ilise passes over the spine of the fourth lumbar vertebra; the 
spine just above is the third lumbar vertebra, and at a point mid- 
way between the two spines is the location for making the puncture. 
The needle should be introduced at a point a little to one side of the 
median line. 

In infants and young children a simple acute otitis media may give rise 
to symptoms simulating cerebral complications, as headache, nausea, 
vomiting, and excessive elevation of temperature (Gradle). If menin- 
gitis is suspected, the diagnosis may be cleared by making a lumbar 
puncture and subjecting the removed spinal fluid to microscopic 
examination. If purulent meningitis is present, the fluid is turbid 
and loaded with pus cells and pathogenic bacteria, especially strep- 
tococci. If the fluid escapes under high pressure, and is clear and 
contains only a few leukocytes and no demonstrable bacteria, serous 
meningitis is present, and a mastoid operation should effect a cure with- 
out resorting to an exposure of the cranial contents other than at the 
atrium of infection, the tegmen tympani or antri. Lumbar puncture is 
negative in reference to the other intracranial infections. 

These and other clinical phenomena usually enable the aural sur- 
geon to differentiate the various extensions of the infection from the ear 
and mastoid cells to the cranial cavity. In the following presentation of 
the intracranial and jugular infections only the more typical clinical phe- 
nomena will be given. (See INIacewen's work on The Pyogenic Diseases 
of ike Brain and Spinal Cord.) 

MENINGITIS SEROSA. 

This disease is of otitic orgin and is characterized by a serous infiltra- 
tion of the pia mater and an increase in the cerebrospinal fluid in the 
suliarachnoid space and in the ventricles of the brain. 

Etiology. — (a) It is more often a complication of chronic otitis 
media and mastoiditis. (6) The channels of invasion may be through 
the tegmen tympani and antri, or through the labyrinth. 

Symptoms. — Headache, dizziness, nausea, vomiting, restlessness, 
ataxia, torticollis, disturbances of vision, etc., are usually present, though 
not all of them at one time. The symptoms are not different from those 
in the suppurative form of meningitis, and it is, therefore, difficult to make 
a diagnosis before operation. If there is a spontaneous cessation of the 
meningeal symptoms, or if they cease after a mastoid operation, the dis- 
ease is probably serous in character, the purulent forms rarely being thus 
favorably affected. Lumbar puncture is negative. 



EXTRADURAL ABSCESS 759 

Quincke's puncture is of little value in the diagnosis, as there is likewise 
a pressure of the serous fluid in the purulent forms. 

Treatment. — A radical mastoid operation and exposure of the dura 
mater at the tegmen tympani and antri should be performed to evacuate 
the extradural accumulation if present. The dura should be opened 
even if pus is not found. If serous fluid is discharged under high 
pressure and in a large quantity, and the meningeal symptoms rapidly 
disappear, the diagnosis of meningitis serosa may be confidently made. 

EXTRADURAL ABSCESS; PACHYMENINGITIS EXTERNA 
CIRCUMSCRIPTA. 

Definition. — An extradural abscess is a localized or circum- 
scribed pachymeningitis. The thin plate of bone between the attic and 
the dura, or between the antrum and the dura, undergoes carious and 
necrotic degeneration, and the dura over this area becomes inflamed, 
throws out a plastic exudate, and is firmly attached to the bone it 
covers. After a time the bone is destroyed and the purulent secretion 
burrows between the dura and the bone, but is prevented from extending 
over a large area by the plastic exudate. It is generally located in the 
middle fossa. 

Etiology. — The abscess usually occurs in chronic otorrhea with 
acute exacerbations of mastoiditis. It also occurs in cholesteatoma 
with suppuration. The cholesteatomatous mass in the attic or antrum 
causes pressure necrosis of the tegmen tympani and tegmen antri, and 
thus exposes the dura of the middle fossa to suppurative infection. 
Acute suppurative otitis media, especially of influenzal origin, may also 
cause it, as the bacillus of influenza is very destructive to bone tissue. An 
infected embolus or a thrombus from one of the veins or its tributaries 
may cause an extradural abscess without bone necrosis. 

Symptoms. — The signs of this condition are not well marked, a 
severe headache with a slight rise in temperature being the most reliable 
ones. The headache is continuous and is referred to the aft'ected side. 
When, however, there is a sudden profuse discharge of pus from the 
ear, the headache and the temperature are relieved or disappear alto- 
gether. If the membrana tympani (drumhead) is observed by reflected 
light, and the pus pulsates, it may be inferred that it has its origin in the 
middle fossa of the skull. That is, the pus conies from a cavity surrounded 
or partly surrounded by a resistant tissue. The dura is such a tissue, 
hence the inference. If the pus comes from a bony cavity, no such pulsa- 
tion is present, unless an artery is exposed by the necrotic process. The 
internal carotid artery ])asses close to the anterior ])ortion of the cochlea, 
and if there is a labyrintiiinesupjiuratioii, and the artciy is exposed, there 
may be a pulsation of the escaping ])us. 

If during a mastoid oj^eration there is a profuse (Hscharge of pns which 
])ulsiites synchronously with the heart beat, there is in all ])rol)abiHly an 
extradural abscess, \\liich may i»e evacuatctj and cnrcd by removing (he 
tegmen tympani and legmen antri. 



760 THE EAR 

Localizing or motor symptoms are absent, as the motor tract of the 
brain is not involved. 

The abscess is not always located in the middle fossa. Necrosis of the 
cells posterior to the labyrinth may occur, and thus communicate with the 
cerebellar fossa back of the pyramid of the temporal bone. Hence, 
vomiting and vertigo may be the prominent symptoms. The headache 
in these cases is referred to the region of the occiput on the affected side. 
The temperature is about the same as in extradural abscess of the middle 
fossa. As the disease progresses, mental dulness and coma develop 
from the increased intracranial pressure, due to the effusion into the 
ventricles. 

In a case recently operated on by nie the patient rapidly developed 
coma during the course of an otitis media and an acute exacerbation of 
mastoiditis on the right side. The surgeon who was in attendance had 
placed the patient in a hospital for observation, and had recommended 
an operation for mastoiditis. This was refused. During the absence of 
the surgeon from the city the coma developed. When I saw the patient 
he was semicomatose. The nurse stated that he had been complaining 
of pain in the back of the head, but did not know to which side he 
referred it. I performed a radical mastoid operation upon the right side, 
and, as I suspected a cerebellar abscess, the operation was extended in the 
usual way to this region, but without locating the abscess. At the post- 
mortem an extradural abscess containing about 2 drams of thin yellow 
pus was found on the opposite side on the posterior inferior aspect of 
the cerebellum. The left ear was not affected. 

Prognosis. — If the abscess becomes latent, and acute exacerba- 
tions of the otitic and mastoid inflammation do not occur, the patient's 
life may not be placed in jeopardy for a long time. If, on the contrary, 
the abscess occurs during an acute exacerbation, or following an acute 
attack of influenza, the abscess may break its bounds and penetrate the 
substance of the brain and lead to a hasty fatal issue. 

If the abscess is recognized, located, and successfully operated on, the 
patient usually recovers. Spontaneous evacuation into the ear or through 
the outer table of the skull may result in recovery. Knapp reports two 
such cases which evacuated near the occipital protuberance, both of 
which recovered. Dench reports 25 cases of extradural abscess, 23 of 
which recovered and 2 died. Of 10 cases occurring in my practice, 
8 recovered and 2 died. 

Treatment. — The treatment is surgical; alcoholic stimulants may be 
given if sepsis is present. 

The surgical treatment of an extradural abscess consists in removing 
the plate of bone underneath which the abscess rests and evacuating 
its contents. If the abscess is in the middle fossa, it can be generally 
reached through the tegmen tympani and antri, which have already been 
exposed by the radical mastoid operation. A carious opening usually 
exists, and this should be enlarged until the plastic adhesion to the bone 
is reached. This should not be disturbed, as to do so opens the avenues 
of infection to the healthy dura beyond it. A curved probe introduced 



LEPTOMENINGITIS DIFFUSA PURULENTA 761 

through the fistulous opening in the roof of the attic or antrum will enable 
the operator to define the outlines of the abscess cavity, and he can thereby 
judge the area of bone to be removed. It will be rarely necessary to 
make an opening through the squamous portion of the temporal bone 
except in those cases due to a thrombus or an embolus, in which case it 
may be necessary to trephine the skull on the afi'ected side. If there 
is a point of tenderness, this may be utilized as a tentative means 
of locating the abscess. If, after making the opening, healthy dura 
is found, introduce a probe between the dura and the bone and pass 
it in various directions in an endeavor to locate the abscess. If 
the abscess is chronic and walled off, do not rupture the plastic barrier 
if it is possible to reach it by making an opening directly over it, as 
to do so may set up a diffused meningitis. If, however, the abscess 
is not directly accessible through an external opening, the plastic wall 
may be broken down and the pus evacuated through the opening already 
made by lifting the dura with a heavy probe and allowing it to escape. 
The dura should then be lifted and the parts irrigated with warm 
bichloride solution, 1 to 5000. 

If the abscess is between the posterior wall of the pyramid and the 
dura, it may be reached through the mastoid wound by extending the 
bony wound from the posterior wall of the antrum backward and to 
the inner aspect of the sigmoid groove of the lateral sinus. If the sinus 
is large and well forward, this route is not available. 



INTRADURAL ABSCESS; PACHYMENINGITIS INTERIOR CIRCUM- 
SCRIPTA. 

This condition is quite similar to extradural abscess, except that the 
dura is perforated and the plastic exudate exists between the dura and 
the pia mater, thus walling off the purulent accumulation from the brain. 
The symptoms are the same as in extradural abscess. The prognosis 
is more grave, as the brain is in greater danger of infection. The treat- 
ment is the same, though the probing must be more carefully prosecuted, 
as the pia mater is more delicate than the dura. 



LEPTOMENINGITIS DIFFUSA PURULENTA OF OTITIC ORIGIN. 

Leptomeningitis may arise in the course of an otitis media or mas- 
toiditis from a perforation through the tegmen tym])ani and antri, the 
carotid canal, the lal)yrinth, and through the sheaths of the anastomotic 
bloodvessel in infiueuza. Ethmoiditis and sphenoiditis may also give 
rise to it. 

Symptoms. Headache, at first remittent and later constant, is 
c-hara((cris(ic of this disease. The temperature is elevated and the face 
flushed. The pulse and respiration are rapid, the latter assuming the 
Cheyne-Stokes type as a fatal issue is approached. Persistent vomiting 



762 THE EAR 

of mucus and bile is present. Mental excitement, as irritability, delirium, 
and extreme restlessness are marked symptoms; as the disease pro- 
gresses, somnolence and loss of memory develop. Rigors are present, 
but not so marked as in sinus thrombosis. 

The muscles of the face and extremities become drawn or contracted, 
but this phenomenon finally centres in the muscles of the neck, and the 
head is retracted. The pupils are contracted. The muscles of the 
abdomen are drawn in and the abdomen is flat. The motor oculi, troch- 
lear, and abducens nerves become paralyzed. 

Spinal involvement is shown by Westphal's symptoms, viz., increased 
tendon reflexes, and paresthesia and hyperesthesia of the extremities. 

By Quincke's lumbar puncture the increased pressure of the spinal 
fluid may be measured, the coagulability of the fluid and the presence 
of streptococci determined. The virulence of the streptococci may be 
tested by inoculating a guinea-pig with it. Coma occurs a few hours 
before death. 

Prognosis. — Death occurs in nearly every case. Operative interference 
is not warranted. 



BRAIN ABSCESS OF OTITIC ORIGIN. 

Bacon emphasizes the significance of a firm, dense mastoid process in 
cases operated upon in which such symptoms as high fever, rapid pulse, 
etc., do not abate after the operation. He thinks it points to cerebral 
complications, and should lead the operator to explore the cranial cavity 
without further delay. This is sound advice. Many cases may pass 
into a most serious condition while the surgeon is waiting, Micawber- 
like, for something to "turn up." If the pus and debris are removed 
and drainage is established, the symptoms should at once become better, 
and they should remain so. If, on the other hand, only the outer pus 
pocket (mastoid antrum) is evacuated, while the inner pus pocket (brain 
abscess) remains closed, the septic symptoms will continue. I cannot too 
strongly impress the needlessness of delay in operating, or doing secondary 
operations upon the cranial cavity, when the septic symptoms continue 
without abatement. The dangers attending the secondary operation 
are small compared with those of delay. 

It is the aural surgeon's business to know when to await developments 
and when he should operate at once. He should either be a surgeon or 
have a close friend who is one. 

When, after a mastoid operation, the fever and pain continue and the 
examination of the fundi of the eyes is negative, the surgeon should not 
be misled by the negative symptoms, as many cases are reported in 
which the subsequent history showed brain involvement to have been 
present. 

J. F. IMcKernon writes that when the occipital pain is not relieved by 
the primary mastoid operation, the aural surgeon should go deeper and 
explore the cerebellar area, in order, if possible, to determine the cause of 



BRAIN ABSCESS OF OTITIC ORIGIN 763 

the pain. He recommends a grooved director for exploring the brain 
substance in place of an aspirating needle, as it allows the thick pus to 
escape, whereas an aspirating needle does not. 

INIcKernon formulates the following indications for exploring the 
cranial cavity when an otitic abscess is suspected: 

1. That a chronic otorrhea is or has been present. 

2. Persistent headaches, general or localized. 

3. Restlessness and irritability of temper. 

4. Tenderness of the affected side on percussion. 

5. Nausea, vomiting, and vertigo. 

6. An almost persistently low temperature. 

7. A slow pulse, later, stupor. Optic neuritis may or may not be 
present; when present it may aid materially in arriving at a diagnosis, 
as may also aphasia and motor disturbances. 

He believes head pain (2) to be the most significant symptom. 

"In the great majority of cases, other than traumatic or pyemic, the 
patient has had a chronic purulent discharge from the middle ear, often 
dating from an attack of one of the exanthematous fevers of child- 
hood, or he has had a chronic ulceration about the nose or mouth" 
(Mace wen). 

The following statement refers to cases of aural origin: I have been 
told so often by patients in my clinic at the College of Physicians and 
Surgeons that they have no discharge from the ear, in which, upon 
casual examination the pus is easily seen. The patients seem to intend 
to convey the idea that the discharge, though present, is not profuse 
enough to run out over the ear and face. Among private patients a more 
exact statement is usually given, as they are more fastidious, and are 
annoyed by even slight moisture in the external meatus. 

As INIacewen says, "The otorrhea may have given little trouble, and its 
long continuance without apparent harmful result may have lulled the 
initial fear, until the ear disease is regarded as of no importance." 

A person thus affected may suddenly become seriously ill after unusual 
exposure or injury to the head, or even without any known cause. Per- 
sistent headache develops without any increase in the pus discharge. 
Other symptoms follow, and the patient applies to his physician for relief. 

There may be a perforation of the tegmen tympani, which has existed 
for years without infection of the meninges. The granulations fill the 
opening and effectually guard the intracranial contents from septic 
infection. Such a favorable result is not always to be expected. In 
removing the granulations from the attic through the external meatus 
great care should be exercised, lest a perforation in the tegnion be tlu'i-eby 
oj)ened and septic infection transmitted to the meninges. 

Symptoms. — According to INIacewen the symptoms of the acute biain 
abscess may be divided into three stages: 

First Stage. — Twelve to seventy-two or more hours. 

(a) \'i()lcnt (usually) pain in the ear which soon extends into the 
temporal region, with shooting pains in the frontal and ()ecii)ilal I'egions. 

(h) \'oniiting without (usually) nausea. 



764 THE EAR 

(c) Rigors occur early and are nearly constant. They may vary in 
intensity from a mere feeling of chilliness to violent shivering and chatter- 
ing teeth. Cutis anserina is well marked. 

{d) The temperature is slightly above normal. 

{e) The pulse is accelerated. 

ij) The tongue is coated and furred. 

(</) Prostration is marked early. 

(h) Otorrhea ceases, or becomes less in quantity. 

Second Stage. — (a) Pain diminished. 

(6) Percussion over mastoid and squamous portions of temporal bone 
on the affected side causes the patient to wince. (Compare the two sides.) 

{c) Cerebration is slow. The eyes have a vacant, dreamy appearance. 

{d) Want of sustained attention, and finally mental obscuration. 




The cortical centres of the cerebrum, to be used in localizing lesions within the skull. 

(e) Inability to apply strength. The strength exists, but the will power 
to use it is gone. 

(f) Temperature about normal or subnormal. 

(g) Pulse slow and full. Sometimes weak and soft (50 to 60 per 
minute). 

Qi) Respirations slow and regular. 

(r) Constipation the rule. 

{]) The urine occasionally retained. 

{k) Loss of appetite (anorexia) the rule 

(/) Vomiting on moving about. No nausea. 

{m) Convulsions occur occasionally. 

{n) Paralysis may occur from brain necrosis and pressure from the 
abscess (Fig. 380) 

(o) The face is that of one who is seriously ill. The gray color described 
by some is not always present. 



THROMBOSIS 765 

(p) The breath is putrid. 

(q) Rigors do not often occur, except upon extension to a new area. 

(r) Emaciation toward the latter part of the second stage. 

(s) The reflexes do not give rehable data. 

(t) Optic neuritis frequent in latter part of the second stage. 

(u) Examination of the ear shows otorrhea and granulations and 
perforation of the drumhead. The curved probe may reveal erosion of 
the tegmen tympani. 

(v) Swelling and redness over the mastoid usually absent in adults. 

Third or Terminal Stage. — The natural termination is in death. 
Surgical interference may avert this if done in the first or early part of the 
second stage. Stupor and coma gradually increase. The abscess may 
break and leak on the surface of the brain or into the ventricles. Such 
an event is attended by vomiting, flushing, restlessness, rigidity of limbs, 
clonic spasms, quick pulse and respiration, and high temperature. 

Prognosis. — Koerner reported 92 cases of brain abscess operated 
upon, with 51 recoveries. The prognosis varies, however, according to the 
stage in which the operation is performed. If operated in the first stage, 
the death rate should be small, perhaps less than 10 per cent.; if in the 
second stage, before stupor develops, it should not exceed 50 per cent. If 
the operation is postponed until encephalitis has become extensive, or 
until the pus has escaped from its sac and invaded the meninges and 
ventricles of the brain, the mortality probably exceeds 90 per cent. 
Taking the cases as they have been operated upon and reported in the 
literature, the average death rate is about 50 per cent. 

Treatment. — (See the Surgery of the Temporal Bone.) 



THROMBOSIS. 

A thrombus is a mass formed in the heart or peripheral vessels the 
component parts of which are derived from the blood (Frazier). They 
are arterial, venous, capillary, or cardiac in origin, and, according to 
their composition, are white, red, and mixed thrombi. 

The following four factors enter into the pathogenesis of a thrombus: 

1 . Infective microorganisms. 

2. Structural changes in the intima of the vessel or organ. 

3. Disturbances of the blood current. 

4. Chemical changes in the ]>lood. 

1. In the non-infective thrombus the microorganisms are absent. It 
is the infective type, however, with which the otologist has to deal. "The 
primary causative factor is a pyogenic organism, the primitive lesion a 
[)lilebitis, and the terminal process a thrombosis or a thrombophlebitis. 
Thrombophlebitis, associated with such general septic processes as 
pyemia and septicemia, was the first to be recognized as of infective 
origin; subsequently, however, the infective nature of thrombophleliitis 
has becMi a(hnitted and recognized in other diseases of infectious origin, 
as in the various so-called infectious diseases" (Frazier). Streptococci 



760 THE EAR 

are the most frequent cause of this disease. A negative bacteriological 
finding does not necessarily preclude an infectious origin, the toxin 
remaining being the exciting inflammatory agent. 

2. The structural changes in the intima are due to the irritation by the 
toxins of the bacteria. The intima becomes rough and adhesive. The 
injured cells of the intima liberate a fibrin ferment which favors thrombus 
formation. The roughened projections of the intima into the lumen of 
the vessel interfere with the velocity of the blood current and thereby 
favor thrombus formation. 

3. The slowing of the blood current cannot alone cause thrombosis. 
If associated with changes in the intima and the presence of microor- 
ganisms, it predisposes to thrombus formation. The slowing of the 
blood current is attended by a rearrangement of the constituents of the 
blood. The white blood corpuscles incline to the periphers^ of the cur- 
rent and are admixed with a few platelets. As the current becomes 
slower, the white corpuscles diminish and the platelets increase in num- 
ber. In some instances a projection from the intima causes a whirling 
motion of the current, which still further favors thrombus formation. 

4. The chemical changes in the blood, while not yet demonstrated, 
seem to be factors in thrombosis. A fibrin ferment is probably liberated 
in the infected thrombus, and it may influence the production of the 
platelets. 

Pathology. — The thrombus is composed of the constituents of the 
blood in varying proportions, and are white, red, or mixed, according to 
whether they are formed in circulating or stagnant blood. If in circu- 
lating blood, they are white or mixed; whereas, if in stagnant blood, 
they are red, and have no clinical significance. Blood platelets form the 
nucleus of the white and mixed variety, though in the later stages they 
may have disappeared. 

According to Frazier, the thrombus, at first composed of the normal 
constituents of the blood, undergoes various changes, which become an 
element of considerable danger. The leukocytes undergo fatty degen- 
eration and necrosis; the red corpuscles are decolorized, irregular in 
shape, and pigmented. The platelets disappear and are replaced by 
fibrinous deposits. Softening or licjuefaction occurs, and the creamy sub- 
stance contains granular debris, pus cells, and microorganisms. It is 
in the septic variety of softening that fragments become separated from 
the thrombus, and, as infected emboli, are carried off by the circulation 
and deposited in the internal organs, usually the liver, kidneys, and lungs, 
where they give rise to secondary or embolic abscesses. 

The terminal stage of a thrombus is organization, or rather a disap- 
pearance of the thrombic material and the deposit of fibrous material. 
At the beginning of organization the thrombus becomes infiltrated with 
leukocytes, and following this there is a proliferation of fixed connective 
tissue cells derived from the endothelium and the other fixed cells of the 
intima. Bloodvessels penetrate the clot and form anastomoses with 
each other and with the vessel walls above and below the thrombus. 
The thrombus is absorbed, and is replaced by embryonic connective 



LATERAL SINUS THROMBOSIS 767 

tissue rich in bloodvessels. The fibrous mass becomes firm, contracts, 
and may completely or partially occlude the vessel. In rare instances 
the fibrous tissue disappears and leaves the lumen of the vessel unim- 
paired. 

Venous thrombi extend toward the heart or with the blood current. 
In thrombosis of the sigmoid or petrosal sinuses the thrombus may 
extend to the jugular vein and completely occupy its lumen. 



LATERAL SINUS THROMBOSIS. 

Etiology. — The causes of infective thrombosis of the sigmoid portion 
of the lateral sinus are chiefly to be found in the loss of integrity of the 
intima of the membranous sinus from the extension of the destructive 
process in suppurative mastoid or labyrinthine inflammation. So long 
as the intima is healthy it inhibits the coagulation of the blood in con- 
tact with it, but where its vitality is impaired by a necrosing mastoiditis 
its inhibitory power is lost and the blood fibrin coagulates on the affected 
area, and a thrombus is thus established. The thrombus may or may 
not occlude the lumen of the vessel. At the beginning it is limited to the 
external or bony aspect of the sinus, as this is the part first involved by 
the necrosis of the bone. The necrosis may extend from the mastoid 
cells of the process or from the labyrinth (in labyrinthine suppuration) 
to the cells lying between the labyrinth and the antrum, and thence to 
the antrum and mastoid cells, from whence it involves the sinus. 

At the beginning the thrombus is not infected. It is only after the wall 
of the membranous sinus has undergone marked deterioration that 
the infective microorganisms penetrate it and lodge in the thrombus. 
There is food for thought in this fact. That is, if the condition is diag- 
nosticated before infection of the thrombus occurs, the infection and its 
evil consequences could be thwarted by an exposure of the sinus and the 
removal of the diseased bone surrounding it without opening the sinus 
itself. Unfortunately, the diagnosis of thrombosis at this early stage is 
extremely difficult to make, and is rarely made except during a mastoid 
operation. 

Symptoms. — The symptoms of lateral sinus thrombosis may be 
(livi<l('(l into three stages, based upon the pathological changes so mi- 
nutely described by Macewen in his masterly work on llir Pi/of/ciiic 
Diseases of ihc Brain and Spinal Cord. 

First Stage. — The thrombus, partial or complete; disintegration not 
estal)lislied. 

(a) Slight fever. 

(6) Rigors, usually present. Slight rigors exceptional. 

(c) Headache, slight or severe, limited to the afl'ected side. 

(d) Slight tenderness over the region of the mastoid emissary vein. 

(r) Sh"ght edema and tenderness bdow (he tij) of tlu> mastoid in the 
posterior triangle of the neck. 

(J) liCukocytosis with increased i)ulyni()r[)ljonnrlcar connt. 



7GN THE EAR 

Second Stage. — The thrombosis, partial or complete; disintegration 
and systemic absorption established. 

(a) Temperature always above normal and distinctly fluctuating. 

ih) Frequent rigors. 

(c) Headache and tenderness over the mastoid emissary vein. 

{d) Edema and tenderness below the tip of the mastoid in the pos- 
terior triangle of the neck. 

{e) Increased leukocytosis and polymorphonuclear count. 

Third Stage. — The thrombosis, partial or complete; disintegration and 
excessive systemic absorption. 

(a) A chill or rigor followed by great and marked fluctuations of 
temperature; sometimes subnormal, and then rapidly rising to 104° 
or 106°. 

(b) Headache, severe, often excruciating. 

(c) ^Marked tenderness over the mastoid emissary vein and the pos- 
terior triangle of the neck. The internal jugular vein may be tender on 
pressure. 

{d) Metastatic pneumonia, enteritis, or meningitis may be present, with 
their characteristic symptoms. 

{e) Still greater leukocytosis and polymorphonuclear count. 

Note. — The leukocytosis and polymorphonuclear count is greater in 
sinus thrombosis than in simple mastoiditis. 

(/) Coma as the fatal issue approaches. 

Early Diagnosis. — If diagnosticated in the first stage, and operated 
at once, nearly all cases recover. If diagnosticated and promptly oper- 
ated in the second stage, before metastatic extension to the brain, lungs, 
bowels, spleen, etc., fully 50 per cent, will recover; whereas, if diag- 
nosticated and operated in the third stage, the mortality rate is very 
high. 

In view of the foregoing facts, it is evident that all cases of suppurative 
otitis media, especially if there is a secondary acute manifestation, 
should be critically studied to detect the earliest sign of sinus involve- 
ment. Such observations cannot be made unless the patient is placed 
in bed, with a trained nurse in attendance, and the temperature, pulse, 
and respiration recorded every three hours. Inquiry as to the presence 
of a unilateral headache, not necessarily severe, should be made two or 
three times daily. The surgeon should examine for tenderness over 
the mastoid emisssary vein and the posterior triangle of the neck. The 
occurrence of a rigor, even if slight, should excite suspicion, and lead to 
most careful inquiry as to all the other symptoms. 

If a diagnosis is not positively made before a mastoid operation is per- 
formed, the sigmoid portion of the sinus should be exposed and its mem- 
branous walls examined. Infective perisinuous abscess may be present, 
without involvement of the intima of the sinus. Sometimes the external 
surface of the membranous sinus is velvety and granular in appearance, 
the smooth surface and pearly gray color normal to the sinus being 
absent. I have seen cases like this recover after exposing the mem- 
branous sinus. The drainage of the perisinuous abscess checked the 



CAVERNOUS SINUS THROMBOSIS 769 

inward extension of the infective process, and thus thwarted the forma- 
tion of the thrombus in the sinus. 

I saw one case in which perisinuous abscess was present and the himen 
of the sinus open, which afterward developed thrombosis of the lateral 
and the cavernous sinuses. The question as to the advisability of opening 
such a sinus is of considerable importance. I believe it should be done, 
and done thoroughly, the sinus being walled off after exploration and 
drained with iodoform gauze. 

A partial thrombosis of the sigmoid sinus may sometimes be demon- 
strated by compressing the sinus with the finger and noting the uneven 
or nodular surface when collapsed. The use of a hypodermic needle is 
useless for diagnostic purposes, as it may penetrate the thrombus, and 
withdraw blood from beyond it. 

In complete thrombosis of the sinus palpation with the finger gives 
the sense of a doughy resistance. After full exposure of the sinus, it 
should be palpated to determine, as far as possible, the probable extent 
of the thrombus. If it is doughy over the full area of the exposure, the 
clot probably extends to or above the knee, and below to the jugular 
bulb. 

The knowledge thus gained may determine the advisability of a still 
further exposure of the jugular bulb. (See Thrombosis of the Jugular 
Bulb.) In complete thrombosis there is no flow of blood upon incising 
the sinus, nor will the hypodermic needle draw fresh blood. 

Prognosis. — The prognosis depends chiefly upon the stage in which 
diagnosis and operative procedures are made. If made in the first stage, 
nearly all will recover. If in the second, about one-half will recover. 
If in the third, the mortality rate is high. If not operated, nearly all 
cases terminate fatally. 

Here is a field in which an early diagnosis and an early operation are 
the means of saving life; whereas a late diagnosis, even with operative 
interference, will in a majority of subjects fail to save life. 

Thrombosis of the Jugular Bulb. — Whiting has formulated the fol- 
lowing test : Compress the membranous sinus as near the bulb as possible, 
and draw the finger upward to empty it; the compression is then re- 
moved, and if the vessel fills from below, it is assumed that the bulb 
is not throml)osed. AUport believes this procedure is dangerous, as it 
may liberate infective clots and disseminate the infection to other parts 
of the body. Such occurrences have not been reported. 

Grunert exposes the jugular bulb by opening the mastoid, exposing 
the sinus, and ligating the jugular. The retro-auricular and cervical 
fjiigular) incisions are then united and the tip of the mastoid process 
is resected. The soft parts are then pulled forward and loosened as 
far as the jugular foramen. The bone should be removed until the 
jugiilai' bull) is ('\|)()S('(1. fSee Surgery of the Temporal Bone.) 

Cavernous Sinus Thrombosis. —Thrombosis of the cavenious simis 
is rai-c. Two cases of otitic origin have occurred in my practice, though 
this is probably an excej)tional experience, as many aurisis of e(|nally 
large experienc(> have rej)orte(| no eases. 
I'.) 



770 



THE EAR 



When of otitic origin, it usually extends from the superior or inferior 
petrosal sinus to the cavernous sinus. When it complicates inflam- 
mation of the nasal accessory sinuses, it extends from the secondarily 
infected eye through the ophthalmic vein to the cavernous sinus. 

The general symptoms are similar to those present in thrombosis 
of the lateral sinus (thrombosis lateral sinus). The characteristic symp- 
tom is the marked edema of the peri-ocular tissues and the protrusion 
of the eyeball, as shown in Fig. 381, drawn from one of my cases. 

Fig. 381 




The author's case of cavernous sinus thrombosis of otitic origin. The drawing shows the case in 
the early stage before the thrombxis had extended to the left side through the circular sinus. 

My first case occurred in a girl, twelve years old, seven years after an 
attack of scarlet fever, at which time she had an acute otitis media 
purulenta. During the interim (except the last week of her life) she 
was said to have had no ear discharge. The mastoid symptoms and 
otorrhea developed rapidly. When I saw her on the third day she was 
greatly prostrated and septic, and one eye slightly protruding. The 
first chill and rigor occurred on the fourth day. The lateral sinus was 
exposed, but was apparently not thrombosed. Death occurred three 
days later. 

In my second case the cavernous sinus was thrombosed secondarily 
to the lateral sinus. The lateral sinus was exposed, and the thrombus 



CAVERNOUS SINUS THROMBOSIS 771 

removed as high and as low as possible without establishing a flow of 
blood. The patient gradually became stupid, finally comatose, and 
died one week after the lateral sinus was exenterated. 

Symptoms. — The symptoms depend on whether one or both sinuses is 
affected. It usually begins in one and spreads to the other through the 
circular sinus. The symptoms shift from one eye to the other, a differ- 
ential point between thrombosis of the cavernous sinus and inflam- 
mations confined to the orbital cavity. 

(a) Pain may be occipital, supra- and infra-orbital, and in the vertex. 

(6) Exophthalmos and edema of the eyelids and side of the nose are 
characteristic symptoms due to venous obstruction. 

(c) Drooping of the eyelids (ptosis), strabismus, and pupillary reac- 
tions due to pressure on the third nerve are also present. 

(d) Edema of the pharynx and tonsil on the same side is occasionally 
present. 

The nerves involved are the second, third, fourth, and sixth, and 
the first division of the fifth. The third is the most constantly involved, 
as is evidenced by the ptosis. The duration of the disease varies from 
a few days to several months, generally only a few days. The death rate 
is extremely high. 

Treatment. — The treatment is chiefly palliative. When tension of the 
conjunctiva is extreme, it may be slit or punctured. The eyeball may be 
removed, together with the thrombosed vessels, with a view of affording 
some relief from the pain and distress. Such interference should be 
undertaken only in extreme cases, as there is no hope of effecting a cure 
by this procedure. Attempts to operate upon the sinus have generally 
failed, though favorable reports have been made. (See Surgery of the 
Temporal Bone.) 



CHAPTER XLVIII. 

THE SURGERY OF THE TEMPORAL BONE. 

The surgical treatment of the diseases and complications included 
in this chapter are: (1) Acute mastoiditis; (2) chronic mastoiditis; (3) 
Bezold's mastoiditis; (4) necrosis of the semicircular canals; (5) necrosis 
and suppuration of the semicircular canals and vestibules; (6) necro- 
sis and infection of the cochlea and semicircular canals; (7) thrombosis 
of the lateral sinus; (8) thrombosis of the jugular vein; (9) thrombosis 
of the jugular bulb; (10) extradural abscess in the middle fossa of the 
skull; (11) serous meningitis; (12) abscess of the cerebrum; (13) abscess 
of the cerebellum; (14) facial paralysis; and (15) postauricular fistula. 

Ossiculectomy. — The removal of the malleus and the incus for the re- 
lief and cure of chronic suppurative otitis media has fallen into disuse 
since Macewen's work on The Pyogenic Diseases of the Brain and S final 
Cord appeared in 1893. His presentation of the efficacy of the radical 
mastoid operation for this purpose was so convincing that it has been 
almost universally adopted by otologists throughout the world. There 
is now a reactionary tendency to differentiate the cases, and to adopt 
various surgical procedures, according to the character of each indi- 
vidual case. In some instances the radical mastoid operation is elected 
as the best method of procedure; in others the mastoid meatus operation 
is elected ; and in still others the otologist is content to remove the granu- 
lation tissue and secretions through the external meatus by means of 
small curettes, the syringe (Figs. 382 and 383), and inflation and irriga- 
tion through the Eustachian tube by means of a Weber-Leil catheter. 

Technique. — The Anesthetic. — Ossiculectomy may be performed under 
local anesthesia, though it is usually quite painful. In my experience 
the most reliable anesthetic mixture is composed of equal parts of co- 
caine carbolic acid, and menthol. Instil a few drops of this mixture into 
the meatus, and at the end of twenty minutes its full anesthetic effect is 
obtained. 

It is usually preferable, however, to administer a general anesthetic, 
as this ensures a painless operation. 

Preparation of the Ear. — The auricle and external meatus should be 
scrubbed with soap and water, and followed by an alcohol bath. A 
cotton-wound toothpick or applicator may be used in scrubbing the 
meatus. If a general anesthetic is to be given, the patient should be 
placed in the hospital the day before the operation, and the bowels and 
diet regulated as for the mastoid operation. 

Incision of the Menibrana Tympani. — The incision may begin at the 
margin, at the junction of the antero-inferior and the anterosuperior 



PLATE Xr 




Base of the Skull: Left Labyrinth Exposed on the Right Side, 

the Grooves in the Base of the Skull are Shown also the 

Sinuses of the Dura Mater. 

Two-thirds Life-size. 

1, Crista frontalis (on the left, beginning of the superior longitudinal sinus); 2, foramen cecum 
(emissarium Santorini); 3, crista galli; 4, lamina cribrosa (olfactory nerve); 5, lesser wing of 
sphenoid; 6, optic foramen (optic nerve, ophthalmic artery); 7, anterior clinoid process; 8, sella 
turcica, fianked by the median clinoid process; 9, dorsum ephippii, with posterior clinoid pro- 
cess; 10, foramen rotundum (second division of fifth nerve); 11, foramen ovale (third division 
of fifth nerve); 12, foramen spinosum (middle meningeal artery and recurrent branch of fifth 
nerve); 13, carotid canal and foramen lacerum anterius (great and lesser superficial petrosal 
nerves. Eustachian tube, and tensor tympani muscles); 14, anterosuperior surface of pyramid; 15, 
cocliiea; 16, semicircular canals; 17, tegmen tympani and roof of antrum laid o]5en; 18, anterior 
condyloid foramen (twelfth nerve); 19, posterior condyloid foramen (emissarium Santorini); 20, 
foramen magnum; 21, superior petrosal sinus; 22, transverse sinus (descending portion); 23, 
transverse sinus (horizontal portion); 24, superior longitudinal sinus and torcular Herophili (con- 
fluence of the sinuses); 2.5, occipital sinus; 26, occipital sinus; 27, vein of aqueductus vestibuli 
(emerging at the external aperture of aqueductus vestibuli); 28, internal auditory vein (emerg- 
ing in the internal auditory meatus); 29, vein of aqueductus cochlea; (emerging at the e.xternal 
aperture of aqueductus cochlea;; 30, inferior petrosal sinus emptying into the cavernous sinus; 31, 
circular sinus (Ridley); 32, groove traversing anterior fossa of skull; 33, sinus of lesser wing of 
sphenoid; 34, groove of meningeal artery; 35, transverse groove through middle fossa of the 
skull; 36, longitudinal groove through petrous portion of temporal bone (tegmen tympani); 37, 
groove through apex of pyramid; 38, transverse fissure (between posterior condyloid foramen 
and foramen magnum); 39, longitudinal groove through posterior fossa of skull; 40, impre.ssio 
carotica (corresponding to the bend in the infernal carotid artery); 41, juga cerebralia and im- 
pressiones digitatii-. (After Mruhl-Politzer.) 



THE SURGERY OF THE TEMPORAL BONE 



773 



quadrants of the membrane (Fig. 384), and be extended upward to the 
malleus, thence downward along the anterior border of the handle to its 

Fig. 382 




Irrigation of the attic through a perforation of the membrana fiaccida. 

umbo, or lower extremity, thence up- 
ward along its posterior border to the 
upper limit of the membrane, and 
thence downward along the posterior 
margin of the membrane to the junc- 
tion of the postsuperior and postinf e- 
rior quadrants of the membrane, as 
shown in Fig. 385. This incision 
makes two flaps of the membrana 
tympani, which drop downward 
and expose the tympanic cavity and 
its contents to view. This incision 
pi-eserves a large portion of the 
membrana tympani and favors a 
speedy regeneration of it in the pro- 
cess of repair. The great objection 
to this incision is that the lower half 
of the membrane interferes with the 
(h'ainage of the tympanic cavity. 

Instead of the above incision, the 
entire membrane, or the fragments 
of it, if it is largely destroyed, may 
be removed by making an incision 

around its entire margin and along bolli l)()nlci's of llic IkiikII 
malleus. This provides for perfect drainage during the after-treatment. 

Removal of ihc Malleus and Jvcvs. — 'J'he malleus should first be 
removed :in<l tlicn llic incus. The attjichinenls of the tensor tympani 




1, the utlic; 2, suspensory ligament of tlie 
malleus; 3, external space of the attic; 4, Prus- 
sack's space; 5, malleus; 6, external meatus; 7, 
incus; 8, ligament attaching malleus to inner 
wall of the tympanic cavity; 9, stapes; ]0,i)n)- 
iiiontiiry; 11, cavern tympani. 

belli iM-nlc 



774 



THE EAR 



muscle and the tendinous attachments of the malleus to the tympanic 
wall should be severed. Various instruments have been devised for this 
purpose, the best of which are Sexton's small angular blades (Fig. 386), 
which should be passed behind the handle of the malleus and carried 
upward to the tendinous attachment of the tensor tympani muscle. It 
should then be introduced through the space occupied by the membrana 
(pars) flaccida, to sever the ligamentous attachment to the outer wall of 
the tympanic cavity. 





Fig. 384. — Right membrana tympani, showing the division into A, postsuperior quadrant; B, 
anterosuperior quadrant; C, antero-inferior quadrant; D, postinferior quadrant. 

Fig. 385. — The right membrana tympani with a perforation at the margin of the postsuperior 
quadrant over the lenticular process of the incus, indicating necrosis of the incus and of the 
mastoid antrum. The line a 6 is the line of incision preUminary to the removal of the malleus 
and incus. The flaps of membrane thus made drop down and expose the upper half of the tym- 
panic cavity to view. 

Delstanche's ring knife may be used to remove the malleus. Its ring 
blade should be insinuated around the handle of the malleus and passed 
upward as far as possible, cutting the attachment of the tensor tympani 
muscle. 

Having thus severed some of the attachments of the malleus, it should 
be removed either with the ring knife (Fig. 387) or with forceps (Fig. 388). 



Sexton's ossiculectomy knives. 




Ring curettes for removing the malleus. 



The ring knife, or dull ring (Fig. 388), should encircle the handle of 
the malleus as high as possible, and then, with a rocking motion, or 
side-to-side motion combined with a downward pull, the malleus is 
dislodged and removed through the external meatus (Fig. 388). 

If the forceps are used, the handle of the malleus should be seized as 
high as possible and rocked from side to side, combined with a down- 
ward pull, and dislodged from its position and removed (Fig. 388). 

The incus is not so easily dislodged from its position, as its long process 



m 



THE SURGERY OF THE TEMPORAL BONE 



775 



is often beyond the grasp of the forceps, and even when it can be seized 
it is so fragile that it is apt to break. The incus hook (Fig. 389) is the 




Showing the severance of the ligamentous attachments of the malleus. After this is done the 
malleus is grasped with the forceps or a ring curette, and drawn downward until its head is dis- 
engaged from the attic. It is then removed through the external auditory meatus. 




Removal of the incus with the incus hook, after tlie remov.il of iljc iriMllcus. 'I'lio I 
be introduced po.sterior to the incus, the incus pu.shed forwiud and dnwiiuaid. If 
backward it is apt to become lodged in the aditus ad antrum. 



776 THE EAR 

best instrument for its removal. Another difficulty encountered is the 
liability to dislocate it backward into the aditus ad antrum, or even into 
the antrum. To obviate this mishap, the incus hook should be intro- 
duced behind the body of the incus and passed upward and forward 
over its body. The hook should then be pressed downward and 
slightly forward, thus dislodging the incus and bringing it into the 
lower portion of the tympanic cavity, where it may be removed w^ith 
the forceps (Fig. 389). 

The stapes is never removed in the operation, as to do so would subject 
the labyrinth to infection. 

Hemorrhage. — Bleeding may be controlled by mopping the tympanic 
cavity with adrenalin or with a hot 1 to 2000 bichloride of mercury 
solution. 

Dressings and After-ireatmeni. — The best dressing is a loosely applied 
strip of sterile gauze extending from the tympanic cavity to the auricle. 
The cavity of the auricle should be loosely filled with gauze and cotton 
and the whole covered with an ethereal solution of collodion, which holds 
in place as effectually as a large and cumbersome bandage (Fig. 420). 

The after-treatment consists in applying similar dressings and the 
cleansing of the tympanic cavity with cotton-wound applicators, infla- 
tion through the Eustachian tube, and the reduction of granulations 
with carbolic acid or dehydrated crystals of chromic acid, for a period 
of about one month, or until the ear is dry. 

In the event that this operation is unsuccessful, either the radical 
operation or the meatomastoid operation may be performed. 



ACUTE MASTOIDITIS. 

The Indications for Surgical Intervention.— It is taken for granted 
that the usual abortive therapeutic measures, as (a) the application of 
leeches (or the artificial leech) over the mastoid process and in front of 
the tragus, (6) the instillation of a 12 per cent, solution of carbolic acid 
in glycerin (A. H. Andrews) into the auditory meatus, (c) free incision 
of the membrana tympani, {d) ice over the mastoid process, (e) heat, 
cathartics, etc., have been used without success. 

1. These and perhaps other therapeutic measures having failed to 
abort the infectious and destructive process in the cavum tympani and 
mastoid antrum and cells, the disease tends to become chronic, a fact 
which may constitute a sufficient reason for performing a simple exen- 
teration of the mastoid antrum and cells. To wait for other and more 
definite indications might develop the necessity for a much more radical 
operation, or even lead to serious intracranial complications, and en- 
danger the life of the patient. Intervention, when threatened chronicity 
is imminent, requires a comparatively simple surgical procedure, which 
almost always results in a permanent cure, often with but little or no im- 
pairment of the function of the ear. 

2. Bulging or sagging of the posterior superior wall of the external 



ACUTE MASTOIDITIS 777 

auditory meatus near the membrana tympani (Fig. 375) is due to the 
involvement of the mastoid cells below and anterior to the antrum (cells 
of Kirchner), and is a positive indication for the mastoid operation. 

3. Pain over the mastoid antrum and tip which is not relieved by the 
application of ice (one to four hours), alternated with heat, over a period 
of from twenty-four to forty-eight hours, is an indication for the simple 
mastoid operation. The pain signifies congestion, edema, or granula- 
tions which block the drainage of the secretions. Pressure, necrosis, 
and toxemia rapidly develop under such conditions, and if the pain 
persists the mastoid antrum and cells should be opened. 

4. Edema and redness of the mastoid region signify blocking of the 
secretions, and, if the condition is not relieved by leeching, ice, heat, etc., 
constitute another indication for surgical intervention. 

5. The presence of a subperiosteal abscess over the mastoid process, 
especially in adults, having its origin through a fistulous opening in the 
mastoid cortex, is an indication for the operation. In infants and chil- 
dren such a condition often has its origin beneath the periosteum of the 
meatus, the mastoid cortex being intact, hence a subperiosteal abscess 
and the infection of the ear and mastoid antrum may be cured by an 
incision (Wilde) through the skin over the mastoid process. 

6. Meningeal irritation (complicating acute mastoiditis), as evidenced 
by convulsions (in infants and children), delirium, intense headache, etc., 
may call for the mastoid operation. 

7. Other and more serious intracranial complications, as circum- 
scribed meningitis (epidural abscess), serous meningitis, thrombosis of 
the lateral sinus, etc., constitute positive indications for the mastoid 
operation. 

The Simple Mastoid Operation in Acute Mastoiditis.— The Tech- 
nique. — The preparation of the patient and anesthesia will not be 
discussed farther than to say that the head should be shaved, scrubbed, 
etc., over an area extending at least three inches from the attachment of 
the auricle, both above and behind it. Otherwise the patient should be 
prepared and anesthetized as for any other major surgical operation. 

The incision back of the auricle should be so extended as to fully 
expose the entire field of the operation. In adults, the primary incision 
(Fig. 390 a a') should begin at the mastoid tip, one-half inch posterior to 
the attachment of the lobule of the auricle, and extend upward behind the 
auricle, gradually approaching its attachment, until, when near the supe- 
rior attachment, it should be about one-fourth of an inch posterior to it. 
It should then be extended anteriorly to a point immediately above the 
su])erior attachment of the auricle (Fig. 300 a). If, u})on retracting the 
posterior flap, the operative field (posteriorly) is not fully exposed, a 
secondary incision (Fig. 300 h h') should be made at right angles to the 
primary one. It should begin on a level with the external auditory 
meatus and be extended backward for a distance of one inch 
(Wliiting). In those cases in which the mastoid cells extend well back 
toward the occiput it will be necessary to extend the secondary incision 
accordingly. 



778 



THE EAR 



The primary incision (Fig. 390 a a') should be first superficially out- 
lined with the scalpel (Fig. 391), to ensure clean-cut edges, proper 
curve, and extension. It should then be carried through the entire 
substance of the skin, subcutaneous tissue, and the periosteum. 

The Elevation of the Cutaneous-jjeri osteal Flajys. — The skin and peri- 
osteum should be elevated together. Great care should be taken to 
preserve the periosteum, as the su]>sequent repair of the wound will de- 
pend somewhat upon the integrity of this structure. With this object in 
view, the author devised the periosteal elevator shown in Fig. 392. The 
periosteal blades are at right angles to the axis of the handle of the instru- 




The postauricular mastoid incision. a a' , the primary incision; h h' , the secondary incision. 



ment. Experience has shown that this angle is best adapted to the 
clean elevation of the mastoid periosteum. The instrument is provided 
with two right-angle elevators, one elevating on the pull, and the other 
on the push. But little difficulty will be experienced in elevating 
the upper two-thirds of the anterior and posterior flaps; whereas, the 
lower third will be elevated with difficulty, as the tendinous fibers of the 
sternomastoid muscle pierce it. The tendinous bands of this muscle 
should be cut with short, blunt scissors from the external cortex of the 
mastoid tip before elevation of the periosteum is attempted. If this is 
not done, long muscle fibers may be pulled from the sternomastoid 
muscle, thus opening avenues of infection in its substance (Whiting). 



ACUTE MASTOIDITIS 



779 



The Anatomical Landmarks. — Having elevated the cutaneoperiosteal 
flapSj the external characteristics of the mastoid process and auditory 
meatus should be noted. To experienced surgeons this requires but a 
few seconds of time. The first concern should be to determine the loca- 
tion of the mastoid antrum, as it forms the deeper landmark of the mas- 
toid process. It is usually located at a depth of about one-half inch 
beneath the mastoid cortex and a little above and behind the cavum tym- 
pani. There are four more or less constant external landmarks which 
will guide the surgeon to the mastoid antrum. The one most constantly 




Mastoid scalpels. 

present is the area of sieve-like perforations in the mastoid cortex just 
behind the external opening of the meatus (Fig. 393). These small 
openings contain minute vessels which bleed after the periosteum is 
elevated. The surface of the bone should be mopped dry, and in a 
moment the bleeding points will appear. Another landmark usually 
present is the suprameatal spine, or the spine of Henle (Fig. 393). It is 
a small triangle or diamond-shaped bony lip projecting outward and 
forward from the posterior margin of the external auditory meatus. 
The point for entering the antrum is immediately behind the spine. 



K^s^ 



=1 



author's mastoid iieriosteal elevator. 



The tliird landmark for locating the mastoid antrum is the suprameatal 
triangle (Fig. 393). The upper boundary of the triangle is formed by 
the lower border of the posterior ridge or root of the zygomatic process; 
the posterior inferior boundary is formed by an imaginary line extend- 
ing from the i)ostorior end of the root of the zygoma to the inferior por- 
tion of the spine of Ilenle, or, if this is not present, to the posterior 
inferior margin of the auditory meatus. An opening made in the anterior 
portion of this triangle near the auditory meatus will enter the mastoid 
antrum. The fourth huuhuark to the antrum is the direction of tlie 
posterior superior \v;ill of the bony ])orfion of the auditory meatus. This 



780 



THE EAR 



is ascertained by introducing a straight probe into the meatus along its 
posterior superior aspect and noting the angle of inclination in relation 




The anatomical landmarks for opening the mastoid antrum. The suprameatal 
triangle, the spine of Henle, and sieve-like depression. 

to the general surface of the mastoid cortex. Having noted the forego- 
ing anatomical landmarks, the exenteration to expose the antrum should 
be begun at the point indicated by the first three landmarks described, 




The Russian perforator. 



and extended inward in a direction parallel with the probe, as sug- 
gested in the description of the fourth landmark. The usual direction 



ACUTE MASTOIDITIS 



781 



of the posterior superior wall of the bony meatus is markedly inward, 
and slightly downward and forward. After excavating for a depth of 
one-half inch (sometimes more, rarely less), the outer extension of the 
mastoid antrum may be looked for. The sinus is sometimes near the 
surface, and may lie immediately beneath the skin. Should the 
mastoid cortex be carious, the fistulous tract may be followed to its 
origin in the antrum or cells without regard to the external landmarks. 
Opening the Mastoid xintrum. — The Russian perforator (Fig. 394) 
or a gouge may be used to expose the mastoid antrum. Personally, 
the author prefers the Russian perforator, as its use avoids the 
shock incident to the blows of the mallet (Fig. 395) in using the gouge. 
If the Russian perforator is used, its tip should be placed in the supra- 
meatal triangle (Fig. 393), with the long axis of the instrument paralle, 
with the probe placed against the posterior superior wall of the meatusl 
as described under External Landmarks. The mastoid cortex is 
then perforated with a boring movement of the perforator, the bone 




Allport's mastoid mallet. 



shavings passing into the hollow chamber of the instrument. The 
instrument should be removed from time to time to examine the bottom 
of the bony wound, to see when a pneumatic space is uncovered. When 
this occurs, a dark spot will be found in the bottom of the wound. 
When the mastoid cortex is carious the tissue may be excavated with a 
curette, the anatomical landmarks being disregarded. A curved silver 
])r()be should })e introchiced into tlic pneumatic space, the curved tip being 
directed anteriorly. If the pneumatic space is the mastoid antrum, the 
tip of the probe will pass forward through theaditus ad antrum into the 
cavum tympani, as shown in Fig. 39G. If the pneumatic space is a 
mastoid cell, the probe will not pass forward through the aditus ad 
antrum. If the sigmoid portion of the lateral siiuis is located anteriorly 
against the posterior wall of the auditory meatus the perforator will 
uncover it, but will not injure its membranous covering. Herein is 
another reason for preferring the Russian ])erf()rator to the gouge. 
As Whiting has so well shown, the external conformation of the mas- 



781 



THE EAR 



toid process will show the position of the sigmoid portion of the lateral 
sinus. The sinus, being a large vessel, requires space; hence the area 
of greatest external bulging or convexity of the mastoid cortex may be 
taken as a guide to the location of the sinus. When the convexity is at 
the middle portion of the mastoid cortex it is w^ell out of the way in open- 
ing the antrum. When, however, the anterior portion of the mastoid 
cortex is elevated, and the posterior wall of the meatus drops at right 




The opening into the mastoid antrum made with the Russian perforator. The fact that the 
silver probe passes forward through the aditus ad antrum into the cavum tympani, is proof that 
the pneumatic space at the bottom of the wound is the antrum and not a mastoid cell. 



angles from it, the sinus is located anteriorly, and will be exposed in 
opening the antrum. In such subjects it may be necessary to open the 
antrum by removing the posterior wall of the meatus after the method of 
Stacke. 

Having exposed the mastoid antrum, its dimensions and extensions 
should be determined with a bent probe introduced through the bony 
wound. The whole outer wall of the antrum should then be removed 
with a gouge and mallet or the rongeur forceps. 



ACUTE MASTOIDITIS 



783 



The Removal of the Mastoid Cortex. — ^The mastoid cortex should be 
removed in parallel shavings (Fig. 397), as recommended by Whiting. 
From three to four grooves are thus made, exposing the superficial cells. 
The gouge may be applied at either the mastoid tip, as shown in the 
drawing, or at the level of the mastoid antrum. Care should be exer- 
cised to avoid injuring the mastoid emissary vein shown at the posterior 
portion of the mastoid process (Fig. 397). This vein opens into the 




The removal i)f the cortex of tlic niastoii 



sigmoid portion of the lateral sinus, and, when injured, bleeds })rofusely 
and persistently. It may be readily closed l)y placing (he tip of some 
blunt instrument against tlie opening of its bony canal and tap])ing it 
smartly with the mallet. 

The Exenteration of tlie Madold Cells. — After the cortex is removed 
the cells should be broken down and removed with the curette and the 
rongeur forceps. If (he intercellular walls are soft or necrosed, they 



784 THE EAR 

may be removed with a curette. If they are firm, the rongeur forceps is 
better for the purpose. The overhanging edges of the mastoid cortex 
should be removed with the rongeur forceps (Fig. 398) until all cells are 
completely exposed and accessible to curettement. I>arge mastoid cells 
are often found in the tip of the process, and they may be the focal centre 
of the infection, pus only being found when these cells are reached. 
The cells should, therefore, be exposed to the tip in all cases, as other- 




The completion of the removal of the mastoid cortex with the rongeur forceps. The cells 
may also be removed with the same instrument. 

wise the focal centre of infection may not be exposed and the operation 
fail of its purpose. All cells should be opened, but not completely oblit- 
erated, as in the meatomastoid and radical operations. 

The Irrigation of the ]]^ound. — As the infective microorganisms in 
acute mastoiditis are usually quite active and virulent, and it is almost 
impossible to prevent them coming in contact with the soft tissues, it is a 
wise precaution to irrigate the wound with a 1 to 4000 bichloride solution 



ACUTE MASTOIDITIS 



785 



at about 100°. The external auditory meatus should also be scrubbed 
and irrigated with the same solution, care being exercised to avoid 
injuring the membrana tympani and dislocating the ossicles. 

The Closure of the Cutaneous Wound. — ^As drainage must be main- 
tained for several days subsequent to the operation, and the cavum 
tympani is not exposed by the operation, it 
is necessary to provide for drainage through ^ig. 399 

the posterior wound. ^ 

The cutaneous wound is not, therefore, 
completely closed at the time of the opera- 
tion. The upper two-thirds is sutured as 
shown in Fig. 399, while the remaining 
lower third is left open for the introduction 
of the drainage tube and gauze. 

The Dressing. — The object of the dress- 
ing is twofold, namely, to promote drainage 
and protect the wound from further infec- 
tion while the process of repair is in progress. 
In order to accomplish the first object, the 
dressing should be so applied as to ensure 
free drainage. According to the author's 
experience, only so much gauze should be 
introduced into the depth of the bony wound 
as to carry off the secretions to the outer ab- 
sorbent dressing. To pack the wound with 
gauze is poor practice, as the gauze becomes 
saturated with the secretions, retains them in 
the wound, where they bathe its walls, and 
retard the reparative process. On the other 
hand, if only a small wick of gauze is carried 
to the bottom of the bony wound the secre- 
tions are carried out as fast as formed, and 

the healing process progresses uninterruptedly and rapidly to recovery. 
The author's practice has been, therefore, to introduce a spirally cut, 
soft-rubber tube, with a small wick of gauze placed loosely in its lumen 
(Fig. 400), into the mastoid wound. xA.fter two years of such practice 
he is convincefl that liealing takes place more certainly and rapidly than 
it did in the cases previously (h'essed with gauze more or less packed into 
the wound. A small wick of gauze is also placed in the external aucUtory 
meatus. The outer absorbent and protective and absorbent dressing 
consists of gauze pads, 5 x 6 inches, placed over the auricle and mastoid 
wound, and held in position witli a bandage applied in fan-shaj)e or a 
half figure-of-eight. 

The bandage should not be ii|>|)li('d undci- (lie cliin or ni-ouiid the neck, 
as it is uncomfoi'liddc ;iiid niuicccssarv. 




Method of closing the mastoid 
incision after the simple mastoid 
operation in acute mastoiditis. 
The spiral rubber tube and gauze 
drain in the lower angle of the 
incision prevent disfigurement. 



In performinK tlic simple mastuid operation for acute mastoiditis it i.s unnecessary to expose 
the external and auditory meatus, as is shown in the drawings. The drawings are tlius nuide to 
show the anatomical landmarks for teaching purposes, and for reference in describing the radical 
and the meatomastoid operations for chronic mastoiditis. 
50 



78G THE EAR 

The After-treatment. — The first dressing should be removed at the 
ex{)iration of three days, the wound cavity gently mopped dry with a 
cotton-wound applicator, and another spiral tube dressing introduced. 
The meatus should also be mopped until freed of secretions, a fresh 
gauze wick applied, and the whole covered with gauze pads, as at the 
first dressing. The suture should be inspected before redressing the 
wound, and if stitch abscesses are present the sutures should be removed. 
If the wound is healthy, they may be left in position until the fourth or 
fifth day. The wound shoidd be dressed daily as described, until the 
secretion diminishes to a small amount, after which the tube should be 




Rubber drainage tube cut spirally with a wick of gauze. This is the only dressing used by 
the author in his mastoid wounds. The usual gauze and cotton dressing are placed externally 
over the tube dressing. The spiral cut provides for drainage the whole length of the tube. 

omitted and only a small wick of gauze introduced. The cavity will 
then rapidly fill in from the bottom with healthy granulation tissue, and 
at the end of from three to six weeks be entirely healed with a slight 
depression at the lower angle of the wound. 

In exceptional cases infection of the labyrinth, sinus thrombosis, etc., 
may develop subsequent to the operation and modify the course of the 
reparative process, or even necessitate the adoption of other surgical 
procedures hereinafter described. 



CHRONIC MASTOIDITIS. 

Chronic mastoiditis, which has resisted simple methods of treatment, 
has, during the past fifteen years, been chiefly treated by the radical 
mastoid operation. Two years ago Charles Heath, of London, called 
attention to the brilliant results he obtained by a less radical procedure, 
whereby the hearing was greatly improved and the disease apparently 
cured. Since then the author has performed twelve meatomastoid 
operations with good results. Koerner, Stacke, and others previously 
described an operation similar to that described by Heath. My method 
differs from theirs, in that I make a complete exenteration of all the 
pneumatic cells of the temporal bone, as in the radical operation, and I 
call the method the meatomastoid operation. The (a) radical and the 
(b) meatomastoid operations will, therefore, be described as remedial 
measures for the cure of chronic mastoiditis. 

The Radical Mastoid Operation. — Technique.— The patient is 
prepared as for the simple mastoid operation in acute mastoiditis. The 
mastoid antrum and cells are exenterated as in the simple operation in 
acute mastoiditis. (See Simple Mastoid Operation, Figs. 390 to 398.) 



CHRONIC MASTOIDITIS 



787 



The Removal of the Posterior Wall of the Bony Meatus. — Having com- 
pleted the exenteration of the mastoid antrum and cells, the posterior 
wall of the bony meatus is removed with a chisel, as shown in Fig. 401. 
In the removal of this wall there are certain anatomical structures which 
may be injured if due care is not exercised to avoid them. These struc- 
tures are the facial nerve, the external or horizontal semicircular canal 
(Fig. 401), and the dura of the middle fossa of the skull. The facial 
nerve emerges from the petrous portion of the temporal bone and passes 
backward along the superior margin of the inner wall of the cavum 




The anatomical landmarks after the complete exenteration of the mastoid process and cavum 
tyrapani. o, the round wndow; h, ridfie of horizontal, semicircular canal; c, the facial ridge; 
d, the stapes in the oval window; e, the dura of the middle fossa exposed through a perforation 
in the tegment antri. 



tympani just above the oval window. It then courses downward across 
tlie inner and inferior wall of the aditus ad antrum, immediately below 
the upper and deeper portion of the bony wall of the meatus (Fig. 401 c). 
From thence it passes downward, deeply buried in the plate of bone 
forming the posterior wall of the auditory meatus, and emerges just an- 
terior to the styloid process. Tiie nerv(> is most liable to injury in remov- 
ing the posterior meiitMl w;ill dircrfly over the aditus ad antrum, as it is 
only protected in tlii> ;iii;i liy ;i tliiii l)iil dense bony covering. Should 
the chisel by any mischance crc^.ss tlie space of the aditus ad antrum 



7SS THE EAR 

(channel of connnunication between the cavum tympani and the mas- 
toid antnim) to its inner and inferior wall, across which the facial nerve 
passes, facial paralysis may follow. In the removal of the posterior 
wall of the meatus the more superficial parts may be removed without 
fear of damaging the facial nerve, while the deeper portion should be 
removed with due regard to the facial nerve wdiich passes through it. 

After the facial nerve crosses the floor of the aditus ad antrum it turns 
sharply downward and emerges near the styloid process. As it makes 
the bend (Fig. 401 c) it rises almost to the level of the anterior portion of 
the annulus tympanicus, to which the membrana tympani is attached. It 
is obvious, therefore, that the lower portion of the posterior wall of the 
meatus cannot be removed deeper than the annulus tympanicus without 
injuring the facial nerve. 

To recapitulate: The upper portion (erect position) of the posterior 
wall of the meatus may be removed in its entirety, or down to the aditus 
ad antrum, wdiereas the lower portion should only be removed down to 
the level of the annulus tympanicus or drumhead. The complete re- 
moval of the wall, in so far as it is compatible with the integrity of the 
facial nerve, is shown in Fig. 401. In the meatomastoid operation the 
removal does not include the annulus tympanicus. When completely 
removed, the upper bony wound extends inward at almost right angles 
to the lateral plane of the head, whereas the inferior bony wound extends 
inward and upward at an acute angle to the lateral plane of the head. 

Another important anatomical structure in the immediate vicinity of 
the facial nerve as it crosses the floor of the aditus ad antrum is the 
external or horizontal semicircular canal (Fig. 401 c). It is located a 
little above and behind, and more superficially, than the facial nerve at 
this point. The precautions taken to avoid injury to the facial nerve 
will at the same time protect the semicircular canal. Indiscriminate 
curettage of the inner wall of the cavum tympani (middle ear) may injure 
either the facial nerve, the semicircular canal, or the stapes and oval 
window (Fig. 401 d). 

All these structures should be constantly held in mind during the re- 
moval of the posterior bony wall of the meatus. The dura of the middle 
fossa (Fig. 401 e) is in but slight danger of exposure, and even when ex- 
posed the danger of infection is slight, as the pathogenic microorganisms 
of chronic infection are but moderately virulent. One of the greatest 
objections to the radical mastoid operation is that the hearing is usually 
impaired by it, especially after a period of one year. The impairment 
of the hearing is due to two factors, namely: (a) to the displacement of 
the foot plate of the stapes in the oval window (Fig. 401 d) at the time 
of the operation, and (6) to the gradual displacement and fixation of the 
foot plate of the stapes by cicatrices and contraction subsequent to the 
operation. On the other hand, it is claimed that the radical operation 
is justified, because in many cases it is the only known procedure that 
will cure the chronic otorrhea and protect the patient from the dangers 
incident to such a pathogenic process in the temporal bone. Life in- 
surance companies have justly refused policies to persons affected with 



CHRONIC MASTOIDITIS 789 

chronic otorrhea, and have granted them when an aural surgeon of 
repute made a written statement that they were cured by the radical 
operation. 

With these facts in mind, the radical mastoid operation has been and 
is still a justifiable procedure in properly selected cases. It is impor- 
tant, however, that the surgeon should take every precaution in the per- 
formance of the operation to preserve the hearing as much as possible, 
consistent with the safety to the life and health of the patient. In order 
to do this, the stapes and the oval window should be respected in the per- 
formance of the operation. Furthermore, the extraction of the stapes 
from the oval window opens an avenue of infection to the labyrinth, 
which, if it occurs, means the almost certain loss of hearing in the ear 
under operation. Fortunately, infection has rarely occurred when this 
accident has happened in the course of the radical operation, as the 
infective bacteria are usually of low virulency. 

The removal of the posterior bony wall of the meatus converts the 
cavum tympani, mastoid antrum, and the mastoid cells into one large 
irregular cavity (Fig. 401), which is easily drained, and if the plastic 
surgery of the meatal skin-flaps is properly executed, results in a cure 
of the disease in more than 85 per cent, of the cases. 

The Removal of the Malleus and Incus. — The removal of the malleus 
and incus, or their necrotic fragments, is an essential part of the radical 
operation, as it has been held that if they are left in position the attic of 
the middle-ear cavity will not be sufSciently drained. This is true to a 
degree, as the bodies of these bones partially form the floor of the attic, 
and their presence interferes somewhat with the exit of the secretions 
from the attic or upper portion of the cavum tympani. Furthermore, 
the complete removal of the bony partition involves the fracture and 
removal of a portion of the annulus tympanicus, to which the membrana 
tympani is attached. This, in addition to the fact that the incus, the 
long process of which projects backward into a sulcus of the bone 
forming the wall of the aditus ad antrum, would, in many instances, 
be dislocated and thus rendered useless as a functionating mechanism 
of the ear. 

For these reasons the malleus and incus should be removed in per- 
forming the radical operation, and the stapes left in situ. 

The technique of the removal of the malleus and incus is com- 
paratively simple if the skin incision or incisions have been sufficiently 
extended to allow the complete exposure of the auditory meatus and 
cavum tympani. The primary skin incision (Fig. 387 a a') should, at its 
upper limit, extend one-half inch more anteriorly than in the simple 
mastoid operation. This will allow the auricle to be retracted far enough 
forward to expose the meatus and cavum tympani. 

When the posterior l)ony wall of the meatus is removed, the middle- 
ear cavity should be packed with cotton saturated with a 1 to 2000 solu- 
tion of adrenalin chloride to check the hemorrhage. After the lapse 
of five minutes it should be removed and the contents of the cavum 
tympani insjx'ctcd. The mannbriuiii oi- Iiiiiidlc of the in;i11(Mis should 



790 



THE EAR 



be seized with small alligator forceps (Fig. 402), dislocated downward, 
and removed. The incus should be likewise removed. Both ossicles 




Noyes' ear forceps. 
Fig. 403 




The removal of the malleus and incus in the radical mastoid operation. 



CHRONIC MASTOIDITIS 



m 



may be removed with a small curette, though the danger of dislocating 
and extracting the stapes is thereby increased (Fig. 403). 

The Removal of Necrosed Bone from the Cavum Tympani. — Necrosis 
of the tegmen tympani (roof of the attic) is present in a majority of the 
subjects of chronic mastoiditis, a fact which gives color to the claim that 
the radical operation should always, or at least usually, be performed 
in these cases. This phase of the subject will be more fully discussed 
under the meatomastoid operation in chronic mastoiditis. 




The curettage of the tympanic end of the Eustachian tube to cause it to close. 
burr or curette should be used to reacli the isthmus of the tube. 



All necrosed tissue in the tegmen tympani, or elsewhere in the walls 
of the cavum tympani, should be carefully but thoroughly removed with 
a small, sharp curette. The region of the oval window and the promon- 
tory, as well as the external semicircular canal, should be inspected, under 
adrenalin, with a strong reflected light for necrosed l)one and granulation 
tissue, and, if found, the proper surgical procedures sliould be instituted 
to remove the conditions of the labyrinth whicli the necrosis and granula- 
tions indicate arc present. (See Surgery of the Ivabyrinth.) 

The Curettage of the EustacJiian Tube. — Many failures attending tlie 
radical mastoid operation are attril)uted to the infected and purulent 
dischariic from the tvun)aiu'f end of the Eustachian lube into (he cavum 



792 



THE EAR 



tympani, subsequent to the operation. With this fact in view, it has 
been recommended that the tympanic end of the tube should be curetted, 
or burred out, to promote its closure by granulation tissue and cicatricial 
contraction (Fig. 404). The author has repeatedly performed this pro- 
cedure, with an almost unbroken record of failures. He attributes the 
failures to the fact that in nearly every instance the suppuration within 
the tube had its origin either in a chronic epipharyngitis or a chronic 
ethmoidal and sphenoidal infection, to which the pharyngitis is often 
due. It may also have been due to the fact that too large a burr was 
used. To be successful, the burr should be small enough to reach to the 
isthmus of the Eustachian tube. If the sinus disease and epipharyngitis 
were first corrected, the curettage of the Eustachian tube would almost 
invariably result in its permanent closure. 

The Plastic Surgery of the Cutaneous Meatus. — The success of the 
radical mastoid operation often largely depends upon the proper use of 
the skin of the auditory meatus in lining the l)ony cavity of the mastoid 
wound. The bone of the mastoid process is frequently sclerosed, and 




Curved flat scissors. 



affords scant soil for the formation of granulation tissue with an epider- 
mal covering. The granulation tissue in such subjects is poorly nour- 
ished, as the blood supply from the underlying bone is scant, and infec- 
tion, therefore, often occurs. The reparative process is thus hindered, 
and the after-treatment may be extended over a period of several months. 
This deplorable state of affairs may be largely overcome by the proper 
disposition of the meatal skin-flaps against the bony walls of the mastoid 
wound. The plastic flaps thus reflected become adherent to the walls of 
the mastoid wound, and thus immediately cover a large portion of the 
bone which would otherwise have to depend upon the reparative granu- 
lation tissue, springing from the bone In addition to this, the full blood 
supply of the meatal flaps ensures the rapid extension of granulation 
tissue from their edges. The scant blood supply from the sclerotic bone 
of the mastoid process is thus complimented by that of the meatal skin- 
flaps, and a speedy regeneration and epidermization of the entire mas- 
toid wound may be confidently expected. In exceptional cases it will be 
necessary to resort to plastic skin-flaps from the margins of the mastoid 



CHRONIC MASTOIDITIS 



793 



wound, or upon Thiersch grafts, as recommended by Charles Ballance. 
(See Thiersch Grafts.) 

The technique of the formation and apphcation of the plastic flaps of 
the meatus to be described is in the main after the method recommended 
by Ballance. The form of the flaps is after Ballance, while the method 
of suturing to hold them in position is, so far as the author knows, 
original with him. 

Before making the incision in the meatus all the tissue on the posterior 
surface of the cutaneous meatus should be removed with short, stout. 




Removing tlie fibrous and muscular tissuo from tlio posteri 
meatus ami couclia, iircparal<ir,\- I" makiui; the pi: 



irface of (lie futauei 
m..alal (la|.s. 



curved scissors (Fig. 405). This should he carried to the extent shown 
in Fig. 407, wiiich shows the whole of the meatus and a portion of^ (he 
concha divested of all tissue except the cartilage of the concha. The 
skin of the concha is included in the plastic flaps. This extensive 
removal of all the tissues covering the jx.slenor half of thv uk^mIus and 
a portion of the concha is essential, beeaus(> by so denuchng ihnn the 
in(>atal Hajis can he iiK)re perfectly and (>x(ensively apphed to the hoiiv 



794 



THE EAR 



walls of the mastoid wound. It is obvious that the meatal flaps, with 
the thick, teii(hnous, fibrous, muscular, and cartilaginous tissues attached 
to them, could not l)c properly reflected and adapted to the walls of the 
mastoid wound. 

Having prepared the meatus and concha as described in the preceding 
paragraphs, and as shown in Fig. 407, the Ballance incision, sometimes 
referred to as the " shepherd's-crook" incision, should be made. ^Yhile 
it is by no means as easy to do as might be inferred from the schematic 




-^T" 



The Ballance incision. The straight portion is made in the posterior inferior portion of the 
meatus, and the curved portion in the concha. The curved portion should be made from the 
anterior aspect of the concha (Fig. 410). 



drawing, it is nevertheless comparatively easy if the superfluous tissue is 
removed as recommended. The blades of a slender divulsion forceps (Figs. 
408 and 409) should be introduced into the meatus with its tips at the inner 
end of the meatal tube. The blades should be spread, to put the meatal 
tube upon a slight tension. The blades of the divulsion forceps should 
be so placed as to have the open space between them at the posterior 
inferior segment of the tube, as the straight incision should be made 
through this portion of the meatus, while the curved portion is made 
from the anterior surface of the auricle, as shown in Fig. 410. If the 



CHRONIC MASTOIDITIS 



795 



cartilage of the conchal portion of the upper flap has not already been 
removed, it should be done at this time. 

Ballance stitches the flaps to the posterior fleshy surface of the ante- 
rior or auricular flap. According to the author's method the plastic 
meatal flaps are anchored to the posterior mastoid flaps, as shown in 




Allport's meatus divulsor. 

Figs. 411, 412 and 413. Two sutures are used in the superior meatal 
flap, one in the conchal portion, and one in the meatal portion. Only 
one suture is used in the abbreviated inferior meatal flap (Fig. 412). 
One thread of each suture is introduced beneath the skin and subcuta- 
neous tissue of the posterior mastoid flap for a distance of three-quarters 




Showing the method of splitting the posterior wall of the skin meatus t( 
for refleoting into the upper and lower portions of the mastoid bone cavity 
ooniplclc cpiilcriiiiziitinn nf its surface after the radical inasloid (>|)(Matii)ii. 



of an inch, and tlieii tlirongli these tissues to the surface of the skin. 
The other thread t)!" each suture is placed in the primary mastoid in- 
cision (Figs. Ill, 112 iiiid 413). Before j)iercing (he mastoid skin witli the 
sutures the auiiclr .iml mastoid flaps sliould be ])lace(l in their projicr 
relations to the head, iiiid traction should be made upon ciicli suture until 



796 



THE EAR 





I'iG. 410. — The Ballancp plastic meatal incision. The incision begins in the posterior wall of 
the meatus (straight dotted line) and extends into the conclia in the form of a shepherd's crook. 
Fig. 411. — The plastic flaps slightly retracted with the anchor sutures in position. 

Fig. 412 




The plastic meatal flaps with the anchor sutures in position. When tlie auricle is placed in 
its proper position and the anchor stitches are drawn over the rolls of gauze (Figs. 413 and 414) 
the plastic meatal flaps will partially line the mastoid wound. 



CHRONIC MASTOIDITIS 



797 



the flaps assume the proper position in the mastoid wound. The 
conchal suture should be thus tested and its location determined. The 
meatal suture of the superior meatal flap should next be tested, and, 
finally, the inferior meatal suture similarly tested, the flaps properly 
located, and stitches in the posterior mastoid flap placed accordingly. 
The ends of the sutures should then be secured with artery forceps until 
the mastoid incision is completely closed by sutures. The anchor 
sutures should then be tied over small rolls of gauze (Figs. 413 and 414), 
beginning with the upper, and thence to the lower ones, until the flaps 




Tlie |)o.staurifular incisions closed, and tlic anclior sutures tied o\er siuail rolls of gauze. The 
anchor sutures retract the plastic meatal flaps into the mastoid wound wlien they become adher- 
ent and partially cover the bony surface with true skin. The whole surface is finally covered by 
extension from the borders of the plastic flaps. 



assume the desired positions in the mastoid wound. The upper flap is 
drawn against the roof of the mastoid wound while the lower flap 
is drawn over the facial bridge. The bony walls being removed, and 
the cutaneous flaps reflected into the mastoid cavity, and permanent 
free drainage and ventilation of the middle-ear and mastoid cavities 
thereby assured, the dressings may be applied via the external auditory 
meatus, as sliown in Fig. 414. Other methods of making the plastic 
meatal fla])s are .shown in l''igs. 415 to 420. 



798 



THE EAR 



After-ireaf)iient. — The primary dressing is identical with that for 
acute mastoi(Htis, with the single exception that the spiral tube and 




III I 



The drainage dressing consists of a spirally cut soft rubber tube with a small wick of 
gauze in its lumen. 



111! 




The Seiherman Y-plastic incision of the concha and skin meatus. Three flaps are formed 
by it, an upper and a lower meatal flap and a V-shaped conchal flap. The cartilage should be 
removed from the V-conchal flap, and each should be drawn backward into the mastoid 
wound by sutures and fixed in position. 



CHRONIC MASTOIDITIS 



799 



gauze are inserted through the enlarged meatal opening in the concha 
(Fig. 414) instead of through the postauricular wound. The distal end 
of the tube is placed into the deepest portion of the mastoid wound. 




Showing the Troutmann tongue flap, which should be reflected into the mastoid wound and held 
in apposition to its posterior surface by small pledgets of gauze packed over cargile membrane. 
Remove the gauze in forty-eight hours. 

This should be removed on the fifth day, or earlier if the temperature 
persistently remains above 101°, or if severe pain develops and per- 
sists. The wound should be mopped dry with a cotton-wound appli- 
cator, inspected for exuberant granulations, and a fresh sterilized tube 
and gauze inserted. If exuberant granulations are present, they should 
be reduced by painting them with carbolic acid, and, after the lapse of 

Fig. 417 Fig. 418 





I'li;. 117. — -The Pause pia.stic incisiiin of tlie meatal skin. 
I'lii. 418. — nie Jansen-Stac^ke pla.stic incision. This flap si 
lus and jugular bulb are exposed. The flap is turned dowii\v:i 



one iiiimitc, willi :ilcoli(,l, lo clicck llic ;icl 
of tiratlUCUt shcllld l.c cnnliiiiird .|;iily f( 

.Vl'ter this tiic liiWc mav l.c al)aii(l()iic(l and 



,.U|,1 l.c US,.,1 

•,1 and JK.ckwa 


when tho sigmoid 
■d :iiid tluis covers 


llic acid. 


This luctliod 


laxs al'tcr 


lie ojx'ration. 


Hwickcf' 


;aii/,c inserted 



800 



THE EAR 



into the wound at its most dependent portion and extended to the 
concha. Small gauze pads should be })laced in the concha of the auricle 





Showing the method of making the Jansen modification of the Stacke plastic flap of the skin 
meatus. The inferior large flap should be reflected into the lower portion of the mastoid wound 
and held in place by anchor stitches. The upper short flap should be reflected into the upper 
liortion of the mastoid wound and held in place by an anchor stitch. 



Fig. 420 



Fig. 421 





Fig. 420. — A collodion dressing used in the after-treatment of operative mastoiditis. A loose 
wick of gauze is inserted into the mastoid wound through the external meatus and covered with 
a film of cotton, which is then saturated with an ether solution of collodion to seal it. 

Fig. 421. — The appearance of the concha and external auditory meatus, after healing is complete. 

to catch the secretions drawn out by the gauze wick. Large pads are 
placed over the auricle and mastoid region and secured with the fan- 
shaped bandage. After the tenth day the large gauze pad and bandage 



CHRONIC MASTOIDITIS 



801 



may be omitted and the dressing applied in the cavity of the auricle 
instead. This should be secured in place by putting a thin film of cotton 
over it (Fig. 420) and painting it with an ethereal solution of collodion 
(Pierce). The mastoid wound usually becomes covered with squamous 
epithelium in from three weeks to two months, though the process may 
cover a longer period of time. Various factors may cause a prolonga- 
tion of the period of repair, chief of which are suppurative inflam- 
mation of the epipharynx, ethmoiditis, sphenoiditis, and a secondary 




Tlie removal of the posterior wall of tlie_exteinal auditory meatus down 
in the meatomastoid operation. Dotted lines indicate the amu 



iiil'cctioii of the iMislacliiaii tube, ('crtain constitutional dyscrasia.s, as 
syphilis, tuberculosis, and struma, may also lower (he vitality of the 
tissues and prolong the reparative process. 

The disfigurement following the Hallance j)lasti(; niealal Haps is slight 
(Fig. 421). It should be said, however, that chondritis of the auricle with 
marked shrinkage and defoi'inity may follow any of fh<' plastic o])erati()ns 
which inchule the cartilage of the conclia. I'lvciy clfoil should be made 
to prevent the infection of the wound cither during oi after the operation. 
51 



802 THE EAR 

The edges of the concha! wound should be touched with carbohc acid to 
seal up the lymph spaces. 

The Meatomastoid Operation. — This operation maybe called a modified 
radical mastoid operation, though it does not include the exposure 
of the middle ear. It does, however, include the plastic meatal flaps 
and the removal of the posterior bony wall of the meatus down to 
the annulus tympanicus. The postauricular wound is closed as in the 
radical operation, and the dressings are applied through the concho- 
meatal wound. 

The advantages claimed for this operation over the radical operation 
in chronic mastoiditis are: (a) The preservation of the function of the 
middle-ear contents, and of the membrana tympani; (6) an improve- 
ment in the hearing, whereas in the radical operation the hearing is 
either unchanged or impaired; (c) the perforation in the membrana 
tympani cavity often closes, after the necrosis and granulations have 
disappeared; (d) the secretions from the antrum and mastoid cells drain 
into the auditory meatus through the opening in the posterior wall of 
the meatus, thus relieving the Eustachian tube of the excess of secretions. 

The principle upon which the operation is based is, that, if ample 
drainage is provided the infectious process tends to subside. The removal 
of the posterior wall of the bony auditory meatus and the retraction of 
the plastic meatal skin flaps into the mastoid wound provide for the 
drainage of the mastoid antrum and cells, and thus remove the stress 
from the Eustachian tube. The Eustachian tube being relieved is usually 
ample to drain the cavum tympani, even when chronically infected. As 
a result, the resistance of the diseased membrane, periosteum, and bone 
is increased, and the infection gradually subsides. The mucous mem- 
brane, periosteum, and bone become healthy and "heal out." 

Heath claims that the removal of the fragments of the malleus and 
incus often disturbs the relation of the stapes to the fenestra vestibuli 
(oval window), and thus impairs the hearing. That is, the stapedius 
muscle pulls the stapes backward and displaces the foot plate of the stapes 
in the window. This could also be obviated in the radical operation by 
severing the tendon of the stapedius muscle. 

The reported cases have been so few in number that it is impossible 
to estimate the place the operation should have in the surgery of chronic 
mastoiditis. The results thus far reported have been so good, and the 
principle upon which the operation is based appears so rational, that the 
technique of the operation is herewith given. 

Technique. — (a) Prepare the patient as for the simple and radical 
mastoid operations. 

f-. (6) Expose the mastoid antrum and cells as in the radical operation. 
^ (c) Remove the posterior bony wall of the auditory meatus down to 
the annulus tympanicus, as shown in Fig. 422. At no time during the 
operation should the membrana tympani and the ossicles of the cavum 
tympani be injured by probing or other instrumental procedure. The 
introduction of a probe into the meatus to determine its depth and direc- 
tion, as recommended in the radical operation, should be studiously 



CHRONIC MASTOIDITIS 



803 



avoided. If this precaution is not observed, the ossicles may be dislocated 
and the hearing impaired. The posterior wall of the meatus should be 
removed as widely as possible so as to provide free drainage and access 




Author's meatal flap retractor. 



to the exenterated antrum and cells through the auditory meatus during 
the after-treatment. It is sometimes necessary to remove some bone from 
the superior wall of the meatus. Enough bony tissue should be removed 




TI,o 


iiioafdiiiastdicl opei.-ili.iM r.jiM|ili'ic. 'I'lic 


iritrun 


1, prpparatory to blowiiiK a blast of aii- llii 


ions 


uiil debris. Tlie author's meatus retract 


)OSMhl 


o during tliis procedure. 



itus ad 



to fully expose the mcmi)rana tyinpaui to inspection al'lcr (he auricle is 
replaced and sutured in position. The prf)j)pr prosecution of (he after- 
treatment will largely depend upon (lie (•(ini|)Ictene.ss witli wliidi this step 
of the operation is carried out. 



804 



THE EAR 



(d) The plastic ineatal flajxs should now be formed as in the radical 
operation. The operator's individual preference may be used, though it is 
essential that the skin of the concha be included in the flaps, so as to 
enlarge the meatal opening and facilitate the application of the dress- 
ings to the mastoid wound and the inspection of the membrana tympani. 
Personally, I have found the Ballance incision the most satisfactory for 
this purpose. The reader is referred to Figs. 406 to 419 for the details 
of the various plastic meatal flaps, with the suggestion that in applying 
them to this operation they should be so utihzed as not to obstruct 
the opening made by the removal of the posterior bony wall of the 
auditorv meatus. 



Fig. 425 




Schema of the ear showing the method of cleansing the tympanic cavity after the meatomas- 
toid operation, a a, mastoid cells; b, antrum; c, aditus ad antrimi; d, membrana tympani; e, 
perforation in the membrana tympani; /, annulus tjTnpanicus; h, external meatus, the posterior 
wall of which is removed; i, the auricle; i, silver cannula introduced through the opening in the 
posterior opening in the meatus, and thence forward into the aditus ad antrum c; air pressure 
appUed with a rubber bulb forces the secretions, granulations, etc., from the t>Tnpanic cavity 
through the perforation (e) in the membrana tympani into the meatus. 



(e) Retract the meatal plastic skin-flaps with the author's retractor 
(Fig. 423) to bring the membrana tympani into view, as shown in Figs. 421 
and 424. This will greatly facilitate the next step in the operation, as it is 
necessary to see the membrana tympani during its performance. If the 
meatal retractor is not used the meatal flaps will constantly obstruct the 
view and hinder the operator in his work. 

(/) Insert a cannula, as recommended by Heath, into the aditus ad 
antrum via the antrum (Figs. 424 and 425), and, with an attached rubber 



CHRONIC MASTOIDITIS 



805 



bulb, send blasts of air into the cavum tympani. The secretions and pedun- 
culated granulations within the middle-ear cavity are thereby blown out 
through the perforation in the membrana tympani into the auditory 
meatus. The middle ear may also be irrigated with the same apparatus. 



Hajek's hand burr. 



(g) If granulations or polypi are thus blown through the perforation, 
they should be grasped by small dressing forceps and removed. If they 
appear at the perforation, but do not protrude through it, they may be 
grasped by gently pressing the forceps blades (one on either side of the 




After tlic exenteration of 
be iiiaiie ^inncif li 



j)erforation) against the margins of the jx-i-rorafion, (liiis bringing tliciu 
within the grasj) of the forceps. The bhists of air should be rcjjcated 
until all the secretions, j)()ly|)i, and debris are cxjiclled from the 



S06 



THE EAR 



tympanic cavity. Tubes of various sizes should be at hand, one being 
selected that fits the aditus ad antrum. If the tube is too small, it 
may pass so far into the aditus as to dislocate the incus and thus impair 
the hearing. It may be necessary to modify the shape of the antral 
aspect of the aditus with a small curette or hand burr (Fig. 426), to 
adapt it to the cannula. 

(h) Having removed the secretions, polypi, and debris from the tym- 
panic cavity with the air blasts and forceps, place a small wet pad of 
cotton over the perforation in the membrana tympani, and a small plug 
of the same material in the antral end of the aditus ad antrum, to keep 
the blood and bone chips from entering the middle ear. 

(i) Anchor the plastic meatal flaps, as in the radical mastoid operation, 
with suitable stitches (Figs, 411 to 414). 

(y) Close the postauricular incision as in the radical operation. 

{k) Introduce the tube dressing (Fig. 414) through the auditory 
meatus into the mastoid wound. Do not place it against the membrana 
tympani, but pass it backward through the opening in the posterior wall 
of the meatus into the mastoid cavity. If other forms of dressing are 
preferred, they should be introduced in the same manner. Whatever 
dressing is employed, it should be loosely placed, not packed, as its pri- 
mary purpose is to facilitate drainage. Some operators recommend that 
gauze be firmly packed into the mastoid wound to "keep down" the 
granulations. If the operation is thoroughly done, exuberant granulations 
will not form; furthermore, good drainage lessens the tendency to the 
growth of exuberant granulations. Exuberant granulations are the 
product of infection, whereas healthy granulation tissue is formed in the 
process of repair. Firmly packed dressings are contra-indicated because 
they obstruct drainage and prevent the regeneration of the tissue. 

The ear should be covered by several large gauze pads, which should 
be removed in from three to five days, the wound gently dried with a 
cotton-wound applicator introduced through the auditory meatus, and a 
new loose dressing applied, which should be changed daily. The sutures 
should be removed on the fifth day. 

The membrana tympani should be inspected daily, especially when the 
blasts of air are forced through the aditus ad antrum. After the mastoid 
wound is cleansed with the cotton-wound applicator the curved cannula 
should be introduced into the aditus via the meatus and the opening in 
the posterior wall of the meatus (Figs. 424 and 425) and blasts of air forced 
through the tympanic cavity to clear it of secretions and granulations. 
All granulations or polypi appearing at the perforation in the membrana 
tympani should be removed with forceps or with caustics. 

The secretions and granulations from the middle ear gradually subside 
as the perforation closes. The mastoid cavity usually becomes filled with 
connective tissue, thiis closing the aditus, or it becomes lined with epi- 
dermis and remains a dry cavity. In either event the Eustachian tube is 
no longer burdened with the secretions from it, but only has those from 
the middle ear to dispose of. 

Of the twelve cases I have thus operated, all have healed and are 



CHRONIC MASTOIDITIS 807 

covered with epidermis. The mastoid wounds are almost filled in the 
process of repair. The membrana tympani reformed in three, the 
hearing returned to almost the normal in all. 

Thiersch Grafts in the Mastoid Wound. — To Reinhard, Jansen, and 
Ballance belong the credit of applying the Thiersch grafts to the mastoid 
wound. Ballance has, perhaps, used it more constantly and frequently 
than anyone else, and his technique is generally followed. Personally 
the author has had but rare occasion to use it, as his cases usually became 
covered with epidermis in as short a time as is claimed by Ballance after 
the use of the Thiersch grafts. In only two cases has it been necessary to 
apply the grafts, and in these they were successfully applied after sec- 
ondary operations. By using the Ballance plastic meatal skin-flaps, and 
fixing them as in Figs. 416 and 423, the author's cases have, with rare 
exceptions, healed with epidermis over the walls of the mastoid wound in 
from three to ten weeks, rarely longer. That this good showing is due to 
other factors than the plastic flaps in quite certain. It is due to several 
factors, chief among which are: (a) The Ballance plastic meatal flaps 
applied after the author's method, (b) The use of the spiral rubber tubing 




Thiersch's graft razor. 

with a small wick of gauze in its lumen as the sole drainage dressing. The 
author is quite sure that tightly packed gauze in the wound interferes 
with drainage and favors the formation of unhealthy granulations, 
though other writers (Allport) claim to use firm dressings to prevent 
and to combat unhealthy granulations. The author does not use 
packed gauze dressings, nor does he have unhealthy granulations to 
contend with in 1 per cent, of his cases, and he therefore concludes that 
the loose dressing is in part responsible for the good results obtained. 
(c) Another cause of the rapid epidermization of the mastoid wound is 
the complete exposure and exenteration of the mastoid antrum and cells. 
The cells of Kirschner, between the antrum and meatus, and those in 
the posterior root of the zygoma are likewise carefully sought for, and 
if ])resent are removed. It has been claimed that no operator can say 
he has removed all the mastoid and associated cells. This is not true, 
as there are many aural surgeons who can and do remove all in every 
radical oj)eration if he so desires. Herein is another reason Thiersch 
grafts are not often required, (d) Rendering the edges iind the surfaces 
of the bony mastoid wound smooth with a curette ;in<l I)iirr also favors 
a rapid reparative process (Fig. 427). 



808 



THE EAR 



If the surgeon finds that a considerable number of his cases pursue a 
prolonged course of healing, he should carefully scrutinize his technique, 
and, if found to be faulty at any point, improve it accordingly, and if his 
cases' still refuse to heal properly he may try the Thiersch grafts. 

Technique. — (a) The grafts may be applied at the close of the primary 
operation, ten days after the primary operation, or after a secondary 
operation. Dench applies the grafts at the close of the primary oper- 
ation. Ballance ten days after the primary operation. The author 
only after secondary operations; that is, only after it is conclusively 
shown that repair will not follow the primary operation. Since adopting 
the technique described in the radical mastoid operation the author has 
not had more than 1 per cent, of cases requiring a secondary operation, 
whereas, in his earlier practice about 10 per cent, required secondary 
operations. 




Thiersch's graft spatula, 



{h) The patient's arm or thigh should be shaved and scrubbed twenty- 
four hours before grafting, a moist carbolized dressing applied, and held in 
position with a bandage. 

(c) The patient should be anesthetized for the reason that (1) it 
prevents the "goose-flesh" contraction of the skin, which so materially 
interferes with cutting thin Thiersch grafts, and (2) it also prevents the 
pain incident to securing the grafts and opening the wound for their 
application. If the grafting is done at the time of the primary opera- 
tion, the patient is already anesthetized and the arm or thigh prepared 
when the mastoid region was shaved. 



tv.^»ii^a^^.^»^ii 



Teasing needle for Thiersch grafting. 

{d) Rescrub the skin after the bandage and dressing are removed. 

(e) With the skin moistened with normal salt solution and drawn 
tight between the forefinger and thumb, remove the thin cortex of the 
skin with a rapid sawing motion with the broad Thiersch razor (Fig. 
429). The razor is flat upon one side, while the other (the upper) is con- 
cave. Normal salt solution should be dropped into the hollow surface 
of the razor to float the graft. The size of the grafts should be about 
2x3 cm., or large enough to cover the entire bony wound. 

(/") Float the graft from the razor blade to the large spatula (Fig. 
429), using a teasing needle in transferring it. 



CHRONIC MASTOIDITIS 



809 



(g) The mastoid wound, having been previously opened and freed of 
all blood and oozing, is made the repository of the graft. With a teasing 
needle (Fig. 430) the edge of the graft is transfixed to the border of the 




The Thiersch graft being applied to the mastoid wound. 

mastoid wound and the spatula gradually withdrawn. The graft is 
thus deposited smoothly and evenly over the surface of the wound. If 
necessary, other grafts are also applied. 




(//) The grafts should be |)r('ssc(l agiiiiisl llic \v;ills of llic woiiin 
small blunt instriiiiicnt iiiilil they are closely adherent to their 
surfaces (Fig. 4:V2). .\ siiimH glass pipette or medicine (hopper 



with a 
nieveii 
iiiiv be 



810 



THE EAR 



used to withdraw bubbles of air from beneath the grafts. Some operators 
prefer to first fill the mastoid cavity with normal salt solution and float 




Mastoid incision in infants, a a, the proper location of tire incision. Tlie lower end of the 
inci.sion should be about one-half inch posterior to its position, in adults in order to avoid injury 
to the facial nerve at its exit from the mastoid bone at h. a b, the usual location of the mas- 
toid incision in children. 

Fig. 434 




Bezold's mastoiditis. The wound is closed with .Michel 's metal clamps, a, spiral tube 
draining the mastoid wound; b, spiral tube draining the abscess of the anterior triangle of the 
neck. An accessory incision is used to drain the abscess, as this will heal quickly after the tube 
is removed. If the tube makes its exit at the lower portion of the primary incision, healing 
will be slow and a scar is left, as this is in the infected field. The portion of the incision 
lielow the mastoid also represents the incision for the excision of the external jugular vein 
and for the removal of the glands of the neck. 



CHRONIC MASTOIDITIS 



811 



the graft upon its surface. The fluid is then gradually withdrawn with a 
pipette until the graft rests upon the surface of the bony wound. It is 



Wfr=^^ 




Allport's mastoid retractor. 
Fig. 436 




Jansen's mastoid letiat-tc 
FiG. 437 




Allport's hoiio-friisliiiiK forcops. 
Fig. 438 




NfcKernon'.s rongeur ff^rcr 



not necessary to engraft the entire surface of the wound, as the interspaces 
soon become covered by extension from the edges of the grafts 



812 



THE EAR 



(i) Ballance formerly covered the grafts with very thin gold-foil to 
prevent the small cotton pads adhering to the grafts and dislodging 
them when the dressing was removed. He now applies the cotton balls 




Jansen's rongeur forceps 
Fig. 440 




Reverdin's needle. 
Fig. 442 



Malleable ear probe. 
Fig. 443 

Hotz's Aural applicator. 

directly to the grafts, with good success. As a matter of fact, the grafts 
will remain in position, if properly adjusted (evenly and closely applied), 
without either gold-foil or the gauze pads. The postauricular wound 



CHRONIC MASTOIDITIS 



813 
the 



should be reclosed with sutures after the grafts are appKed and 
subsequent dressings applied through the enlarged auditory meatus. 

(j) The small cotton balls are used to hold the grafts in apposition to 
the granulating bony wound, and they should be removed on the third 
day. Portions of the grafts will not "take" or grow, hence necrosis 
occurs, giving rise to a horrible stench. The engrafted area should be 
gently mopped dry with a cotton-wound applicator, the necrosed particles 
removed, and a fresh dressing applied. The dressing should be renewed 
daily, as after the mastoid operation. 



Fig. 444 



[msizszSH 



Scheibel's suture forceps. 



mmmmmm^^i^i 



Michel's metal clamp suture. 
Fig. 446 




Michel's suture clip forceps 
Fig. 447 



=55 



Se.xton's ear knife. 



It should be l)orne in mind, however, tiiat Thiersch grafts will rarely 
be necessary if the cutaneous portion of the external auditory meatus is 
j)r()])erly and intelligently utilized to line the mastoid wound, and if the 
cells are c()mj)letely e.xenterated and the whole .surface rendered smooth 
with ii cnrcKc and burr. 

The Mastoid Operation in Infants and Young Children. As (he ina.s- 
toid tip and cells are but slightly develojH'd before the age of ])uberty, 
the technif|ue of the mastoid ojx'ration should be somewhat modified. 
The rudimentary tip of the nnisloid process is located nnicli liiulicr niid 
more posteriorly than in ndults. 



814 



THE EAR 



The postauricLilar incision should, therefore, begin higher and more 
posteriorly, as shown in Fig. 433. Furthermore, the facial nerve makes its 
exit from the styloid foramen quite near the surface, and, if the incision 
is made as in the adults, may be injured and result in facial paralysis. 
The mastoid antrum is almost or fully developed at birth, and is often 
the only })ortion of the mastoid bone involved. 

The Siirgical Treatment of Bezold's Mastoiditis. — The early surgical 
treatment is the only procedure that is applicable in this affection. The 
usual mastoid incision is made with an extension downward beyond the 
tip of the mastoid parallel with the anterior border of the sternomastoid 
muscle to the lowest portion of the brawny swelling of the neck. The 




aiMl gouges. 



aponeurosis of the sternomastoid muscle is divided and retracted. The 
mastoid is opened from below upward, toward the antrum. All the 
mastoid cells are thoroughly curetted until the perforation in its inner 
plate is located. The perforation is followed into the loose tissues of the 
neck, and the granulations removed with a dull curette. The rough 
projections of bone are smoothed with a burr or curette and the ragged 
edges of the muscles are trimmed off with scissors. If the abscess has 
burrowed into the neck anteriorly or posteriorly, it is necessary to lay it 
wide open and thoroughly remove all diseased tissue with a curette. The 
mastoid portion of the incision should then be closed, and a spiral tube 
with gauze in its lumen, the distal end of which is placed in the mastoid 
wound (Fig. 434). If the abscess extends into the neck, the incision 
should be closed over another spiral rubber tube, which is allowed to 
drain through a separate incision back of the lower end of the neck 
incision, as shown in Fig. 434. 

The dangers attending this operation are the wounding of the facial 



NECROSIS AND SUPPURATION OF THE LABYRINTH 815 

nerve at its exit from the bony canal in the mastoid process, and the 
spinal accessory nerve going to the traspezius muscle. If this nerve is 
wounded the shoulder will droop. The lateral sinus is also in close 
proximity to the perforation, hence great care should be taken in oper- 
ating in this region. 

If the disease is early recognized and prompt and thorough surgical 
measures are instituted the prognosis is fair, although the recovery may 
take several weeks, as the healing of the wound after such an extensive 
operation requires considerable time, and not infrequently a secondary 
abscess forms in the neck because of poor drainage. 



NECROSIS AND SUPPURATION OF THE LABYRINTH. 

The extent to which the labyrinth may be surgically exenterated is still 
to be determined by additional experience. That it may be successfully 
invaded within certain circumscribed areas has been already demon- 
strated. The dangers arising from the possible and probable extension 
of the infection from the labyrinth to the cranial contents are so grave 
that the surgeon is justified in opening the labyrinth, at least sufficiently 
to establish free drainage of the cochlea, vestibule, and the semicircular 
canals. The dangers attending the complete exposure of the two and 
one-half coils of the cochlea are so great that it is extremely doubtful if 
such an operation should ever be attempted. Richards, in a recent 
article, reported the complete exposure of the cochlea. He calls attention 
to the danger zones, or points of anatomical vulnerability, which should 
be carefully considered in performing the operation. In the description 
of the technique these zones will be more fully discussed. 

General Technique. — As the suppuration and necrosis of the labyrinth 
is usually associated with and is secondary to mastoiditis, the prelimi- 
nary stage of the surgical treatment of the labyrinth disease is the radical 
mastoid operation. Indeed, the disease of the labyrinth is often only 
discovered during the course of the mastoid operation, though if the 
functional tests of hearing were uniformly used in al^cases of mastoid- 
itis, previous to the operation, the disease of the labyrinth would nearly 
always be determined before beginning the mastoid operation. Richards 
reports cases in which the functional tests failed to indicate the laby- 
rinthine disease. He does not, however, fully describe the nature of the 
tests employed, and the author is inclined to suspect that he is mistaken 
in his suggestions in relation to the unreliability of the tests, for it has been 
generally conceded that laVjyrinthine disease may with a fair degree of 
certainty be demonstrated by the functional tests of hearing when care- 
fully and understandiiigly aj)j)lie(l. 

Richards very ])roj)erly divides the lal)yrintliine cases into two classes, 
namely: (1) Those in which the horizontal (external) semicircular canal 
is alone necrosed, and (2) those in which the cochlea, vestibule, and semi- 
circular canals are'^involved. 

In the first class of cases the surgical treatment is quite simple, and does 



81() THE EAR 

not require special preparation of the surgical field. In the second he 
recommends a wider exposure of the cavum tympani than is required in 
the radical mastoid operation. If the extensive exenteration of the laby- 
rinth recommended by him in extreme cases is to be performed, the 
exposure should be as shown in Plate XII, as a less extensive exposure 
would not allow the instrumentation necessary to successfully accomplish 
the Avork. If only tiie bony wall between the oval and round windows 
and the portion of the promontory covering the first or lower half of the 
first coil of the cochlea are to be removed, a less extensive exposure of 
the operative field will be required. 

The Anatomical Landmarks. — The radical mastoid operation is first 
{performed in the usual manner, the bony capsule of the sigmoid portion 
of the lateral sinus (Plate XII, n) being fully exposed by removing 
all cells and cancellous bone in front of and above its knee; the angle 
above the knee and posterior to the antrum is completely exenterated, 
thus giving the necessary space for introducing the instruments in open- 
ing the canals (bed); a portion of the posterior zygomatic root and 
upper wall of the meatus are also removed to give better access to the semi- 
circular canals and the petrous portion of the pyramid. The deeper por- 
tion of the floor of the external auditory meatus is removed to expose the 
hypotympanic space. The anterior w^all of the external auditory meatus 
is removed {i) to expose the cochlea in front, and the anterior wall of the 
Eustachian tube {h), which should be removed. The stapedius muscle 
should also be divulsed. As the carotid canal is immediately behind the 
posterior wall of the Eustachian tube, care should be exercised to avoid 
injuring it in curetting the tube, a procedure recommended by Richards 
to prevent hemorrhage, which would otherwise obstruct the view of the 
operative field. The carotid artery (j) is shown passing upward parallel 
with the ramus of the jaw, and upward just in front of the cochlea, where 
it makes a sharp turn forward and inward, a very thin plate of bone 
separating it from the posterior wall of the Eustachian tube. The pro- 
montory {q) and the oval and round windows (e /) are fidly exposed to 
view. The facial nerve (a a a) as it makes its exit from the Fallopian 
canal and the bone covering it in its upper course are shown clearly dis- 
sected. The greater portion of the lower wall of the meatus is removed (Ic) . 



THE SURGERY OF THE HORIZONTAL SEMICIRCULAR CANAL. 

When only the exposed wall of the horizontal semicircular canal is 
necrosed the surgical treatment is usually very simple and easy of execu- 
tion. This canal crosses the floor and inner wall of the aditus ad antrum 
(Plate XII, h), the point of greatest constriction between the cavum 
tympani and mastoid antrum, where it is exposed to great irritation by 
the constant discharge of infected secretions (Richards). In performing 
the mastoid operation this area should always be inspected for caries and 
granulations, and if present they should be removed, the diseased process 
being followed to the extent it involves the canal or system of canals. 




The Exposure Required for an Extensive Operation 
upon the Labyrinth. 

a, a, a, the facial ridge and nerve; b, the horizontal semicircular canal; c, the oVilique semi- 
circvdar canal; d, the perpendicular semicircular canal; e, the oval window; /, the round 
window; g, the promontory; k, the tympanic end of the Eustachian tube; i, the fragment of 
the anterior bony wall of the meatus; ;', the internal carotid artery; k, the remaining portion 
of the floor of the meatus, the deeper portion of the floor of the meatus has been removed to 
expose the hypotympanum; /, the internal jugular vein and bulb; w, a section of the bone 
covering the facial nerve; n, the sigmoid portion of the lateral sinus. 



i> 



THE SURGERY OF THE HORIZONTAL SEMICIRCULAR CANAL 817 

Technique. — The carious wall of the canal may be removed with a 
sharp curette, due precautions being taken to avoid the ridge of the facial 
canal (a, a, a), which is situated just below and anterior to the carious 
wall of the semicircular canal. The curette should be directed back- 
ward and upward away from the facial ridge. Richards prefers to 
remove the diseased area with a small sharp chisel, the cutting edge of 
which is placed well above the facial ridge and is directed upward and 
inward to prevent fracture of the facial canal. Bourguet's method of 
opening the horizontal canal is, perhaps, the safest and best. He has 
devised an instrument (Fig. 449) for the protection of the facial nerve 
during the procedure for the opening of the canal. The instrument is 
provided with a semilunar plate, 3x2 mm. in size. The convex border 
of the plate has a heel or toe projecting from it somewhat like the toe of 
a horseshoe. The heel or toe is inserted into the oval window, while the 
convex border of the plate is directed upward. The body of the plate is 
thus located over the facial canal. A^Tien the instrument is thus adjusted, 
the convexity in the plate is a guide to the junction of the horizontal and 
perpendicular semicircular canals. A small sharp gouge is placed in the 
convexity of the plate, and with a few rotary motions it penetrates the 




Bourguet's guide and protector. 

bone and exposes the ampullar space beneath the angle. The external 
arm of the horizontal semicircular canal may then be exposed to its 
posterior limit, and, if necessary, the external arm of the perpendicular 
canal may also be exposed by removing its outer wall upward from the 
primary opening at the petrous angle of the two canals (Fig. 4.10). 

The Bourguet protector and guide is in position, protecting the facial 
ridge and guiding the gouge to the petrous angle at the junction of the 
two canals. 

Having thus removed the necrosed tissue, a small wick of gauze should 
be ])laced against the opening and the mastoid wound loosely packed 
witli gauze. The disturl)ance due to the opening of the canal, as tlie loss 
of equilibrium, dizziness, nausea, vomiting, and nystnginns, will dis- 
appear within a few hours or davs. 

The Complete Exenteration of the Semicircular Canals. — When the 
entire system of sciiiicircnlnr ciinals is filled willi gi-anulalions it may 
become necessary to open them (lirough their entire extent. If they are 
only infected and contain pniiilcnl matter, the opening at the jjctrous angle 
of the horizontal and j)erpendicular canals and the removal of the outer 
wall of the horizontal canal may be sufficient to establish drainage of the 
52 



818 



THE EAR 



entire system. Slioiild this be regarded as insufficient, because the 
canals are filled with granulations, the entire system should be opened. 
The hearing is necessarily greatly damaged when only the outer wall of 
the horizontal canal is opened, as described in the preceding section. 
There is, therefore, no objection to opening all the canals, as the hearing 
will not be rendered worse by it. The chief objection is the difficulty 
involved in the procedure and the possible fracture of the cranial plate 
on the superior and posterior surfaces of the petrous portion of the tem- 
poral bone, and the danger from the meningitis which may follow. The 
complete exposure of the bony walls of the canals before opening them 
will largely obviate these difficulties. 



m 




Schema showing Bouiguet's operation upon the horizontal semicircuJar canal. The facial 
nerve is not actually exposed in tlie operation. 

Technique. — (a) Complete the radical mastoid operation. 

(6) Remove the portion of the zygomatic root and of the roof of the 
external auditory meatus, as shown in Plate XII, to facilitate the use of 
the curette in removing the bony tissue surrounding the canals. 

(c) Having exposed the contour of the canals to view (Plate XII, h, c, d), 
introduce Bourguet's guide and protector (Fig. 449) with its heel or toe in 
the oval window and its semilunar plate over the facial ridge, as shown in 
Fig. 450. 

{e) Proceed to open the petrous angle of the horizontal and perpen- 



THE SURGERY OF THE VESTIBULE 819 

dicular canals as described in the Surgery of the Horizontal Semicir- 
cular Canal (Fig. 450). 

(/) Extend the opening upward and backward, thus removing the 
outer walls of the horizontal and perpendicular semicircular canals 
(Fig. 451). 

ig) With a small curved gouge introduced above and beyond the outer 
limit of the horizontal canal (Fig. 451) remove the superior wall of the 
oblique canal. 

Qi) Proceed to complete the opening of the horizontal and perpendic- 
ular canals with the small curved gouge and small thin chisel. The 
major portion of the work should be done with the gouge, a rotary or 
boring motion being used, as the blows of the mallet are liable to fracture 
the bone in unexpected directions and lead to the dangers of meningitis. 

(i) Endeavor to open the upper portion of the vestibule, as this will 
ensure better results, as the semicircular canals open into it. This should 
be done with a small thin chisel curved on the flat. The petrous angle 
of the horizontal and perpendicular canals, directly above the oval 
window, should first be opened as shown in Fig. 451, and the chisel used 
to extend the opening downward to the vestibule. The force of the blows 
of the mallet should not be allowed to be expended upon the facial ridge. 
That is, the chisel should be well above the facial ridge (not resting upon 
it), as to use the facial ridge as a fulcrum in loosening the chips of bone 
might fracture it and cause facial paralysis (Richards). 

Xj) The dressings and after-treatment should be as described in the 
Surgery of the Horizontal Semicircular Canal. 

Richards says that this route to the vestibule is safer than that via the 
inner wall of the cavum tympani, as there are no vulnerable points to be 
encountered except the facial ridge, whereas, in opening it by removing 
the bridge of bone between the oval and round windows and a portion 
of the promontory, the inner thin wall of the vestibule is more liable to 
injury, especially as the vestibule is shallow at this level and its inner 
wall very thin. 

THE SURGERY OF THE VESTIBULE VIA THE INNER WALL OF THE 
CAVUM TYMPANI BELOW THE FACIAL NERVE. 

When granulations and pus extrude from the oval window, the vestibule 
is profoundly affected and should be opened. Indeed, the cochlea, or 
at least the lower turn of it, is also often involved. It is imperative that 
the vestibule be opened, the granulations removed, and better drainage 
establislied. It may be necessary to exenterate the semicircular canals, 
as descril^ed in the preceding sections, as tliey may also be involved. 

Technique. — Bourguet's method will be adhered to in this descrip- 
tion. 

(a) '^i^ie radifnl iniisloid operation. 

(6) Check the hemorrhage by curetting the tympanal end of the 
Eustachian tube (Fig. 401). Also apply pledgets of cotton saturaicil with 
adrenalin solution to the cavum tympani. 



S20 



rilE EAR 



(c) Remove the pledijets of cotton after a few minutes, and introduce 
the heel of Boui-fjuet's protector and guide into the oval window, as shown 
in Fig. 450, to protect the facial nerve from injury. 




Schema showing Bourguet's operation upon tlie semicircular canals, vestibule, and cochlea. 
The semicircular canals are opened, as shown in Fig. 450, with the protector and guide in posi- 
tion. The facial nerve is not exposed in the actual operation. 

{d) Remove the bridge of bone be- 
tween the oval and round windows 
with a thin sharp chisel, thus expos- 
ing the lower space of the vestibule 
(Fig. 451). 

{e) Enlarge the opening, if neces- 
sary, to expose a portion of the lower 
coil of the cochlea (Fig. 451). This 
figure also shows the horizontal and 
perpendicular semicircular canals 
opened. 

(/) Gently remove granulations 
from the vestibule, and bear in mind 
that the inner wall of the lower por- 
tion is thin and easily fractured. 

ig) The after-treatment is as here- 
tofore described. 




Schema showing a cross-section througli 
the cochlea from ajjex to base. The cen- 
tral shaded portion (a) is the modiolus. If 
more than the ujjper apecial coil is removed, 
the internal auditory canal (h) at its base 
would be opened, thus exposing the patient 
to the dangers of meningitis. 



THE SURGERY OF THE VESTIBULE 



821 



The Partial Exenteration of the Cochlea. — The extent to which the 
cochlea may be exenterated is still an open question. According to 
Richards, it may be opened in its entirety; that is, its two and one-half 
coils may be completely uncapped. To do this it is necessary to remove 
the upper coil and a portion of the modiolus. Herein lies the danger. 
The modiolus (Fig. 452) is a hollow cone at its base, but is solid at its 
apex, which supports the cupola of the cochlea. If the modiolus is 
removed so low or deep as to open the cone-shaped cavity at its base, 
the cerebrospinal fluid will escape into the cavum tympani, and patho- 
genic microorganisms may enter the cranial cavity and cause meningitis. 




An extensive exposure of the canals and cochlea. The apccial whorl is removed. A 
extensive exposure is attended by great danger, and should rarely be attempted. 



In attempting to remove the apex of the modiolus the blow of the mallet 
may accidentally fracture it at its ba.se (Richards), and thus cause 
leakage of the cerebrospinal fluid, meningitis, and death. 

It is obvious, therefore, that under nearly all circumstances the uncov- 
ering of the cochlea should be limited to the removal of the outer walls of 
the coils, the modiolus and dee})er walls being unmolested. In this 
description the limit of safety will be observed, and it is only wlien the 
cochlea is choked with granulations, jiiid necrosis Is pi-cscnl, Ih.il Ihis 
much of an exposure is justifiable. 

Technique. — (a) Preliminary radiciil innsloid opci'iilion, |)his llic mhhc 
extended exposure shown in I'late XII. 



822 



THE EAR 



(b) Check hemorrhage with adrenahn and the curettage of the Eusta- 
chian tube. 

(c) Expose the vestibule and semicircular canals as previously 
described. 

(d) Remove the lower promontory wall covering the first half of the 
first coil of the cochlea, as shown in Fig. 451. A small chisel, a little 
wider than the cochlear canal, should be used to uncap it. The chisel 
should be directed inward and backward, carefully following the canal 
as it curves upward and disappears in the deeper structures of the bone, 
when the dissection should be discontinued. 




Richards' radical operation upon the cochlea and canals. The cupola or apecial whorl is 
removed, including the modiolus. This radical exposure of the cochlea should rarely be per- 
formed, and only then by a surgeon qualified to do it. 



(e) Next uncap the cupola, first locating it by noting the contour of 
the inner wall of the cavinn tympani at a point above the anterior exten- 
sion of the lower coil already exposed. The slight elevation at this point 
gives the location of the cupola or apex of the cochlea. A small gouge 
is better for this part of the procedure, as it may be rotated, thus boring 
an opening into the upper coil of the cochlea. The outer wall of the bone 
may thus be removed from the upper coil, or coil and one-half (Fig. 453). 
Having exposed the outer aspect of the coils of the cochlea, cease the 



THE SURGERY OF THE VESTIBULE 



823 



operation without attempting to extend it farther, as to do so might, and 
probably would, end in meningitis and death. 

The dressing and after-treatment are as previously described. 

The Complete Exenteration of the Cochlea. — As already stated in 
the preliminary discussion under Partial Exenteration of the Cochlea, 
the complete exenteration is rarely, if ever, justifiable, certainly not in the 
hands of the average surgeon, unless he has done extensive dead-house 
work to prepare him for it. Even then the dangers are great and almost 
beyond control. Richards had two deaths from such operations, which 
he ascribed to operative interference. He states, however, that he believes 
he could in future avoid such accidents. In the meantime we should 




Avenues of approach to brain abscess, a, through the squamous plate to the temporosphe- 
noidal lobe; 6, through the tegmen tj-mpani to the temporosphenoidal lobe; c, through the mas- 
toid wound to the cerebellar fossa; d, through the cranial cortex (one and one-quarter inches 
jjosterior to the cavnm tympani) to the cerebellar fossa. 



remember that the operation, even in the hands of an expert who has 
devoted much thought and deadhouse work, as well as work upon the 
living, to it, is frauglit with extreme hazard. 

Technique. — The technique of the complete exenteration of the laby- 
rinth will not be given, as it is not the author's purpose to recommend it 
as a justifiable })rocedure, at least in the j)resent status of the subject. 

In Fig. 454 is shown the complete exposure of the cochlea, its cuj)ola or 
upper coil being removed with the apex of the modiolus. The black 
spot in the centre of the coils is an opening into the internal auditory 
canal (Fig. 452 h), through which cerebrospinal fluid would escape, and 
through which infection of the crani.-il coiilcnts might occur. ^)nly the 



824 THE EAR 

basal coil and half of the second remain. The vestibule and all of the 
semicircular canals are also shown exposed by surgical interference. 

Caution. — Before undertaking the surgery of the labpinth the 
otological surgeon should consider the following facts : 

(a) But few cases of otorrhea and mastoiditis have been found to be 
complicated by suppurative labyrinthitis, though doubtless many such 
complications have been present and not discovered. 

(fc) Most of the labyrinthine suppurations observed have not been 
treated surgically, and in nearly every instance recovery has occurred. 

(c) Those operated have invariably been followed by marked deafness, 
whereas those not operated have been attended by less pronounced 
deafness. 

{(J) In view of these facts surgical intervention should be undertaken 
with reluctance, except in those cases in which the deafness is already 
profound, or in which meningeal irritation is already present, or appears 
to be imminent, as shown by the location and extent of the morbid 
lesions. 

Facial Paralysis Resulting from the Surgery of the Labyrinth. — 
Facial paralysis resulting from the surgery of the labyrinth, as described 
in the above surgical procedures, should only occur in those cases in wdiich 
the facial canal is involved in the necrotic process. It is never necessary 
to uncover the facial nerve to expose the semicircular canals, vestibule, or 
cochlea sufficiently to establish good drainage. Accidental injury of the 
nerve may usually be avoided by heeding the precautions given in the 
descriptions of the various surgical procedures. Bourguet's guide and 
protector is a valuable addition to the instrumentarium, and largely 
solves the problem of protecting the facial nerve as it crosses the upper 
and outer wall of the vestibule. The vestibule may be opened above the 
facial nerve or below it, as described, but under no circumstances, other 
than the presence of marked necrosis of its bony canal, should the bridge 
of bone containing the nerve be removed. While facial paralysis may, 
and has, followed the surgery of the labyrinth, it may, with added experi- 
ence and an improved technique and instrumentarium, be avoided. 



THE SURGERY OF BRAIN ABSCESS. 

The Surgery of Cerebral Abscess. — Abscess of that portion of the 
cerebrum embraced within the temporosphenoidal lobe may be opened 
through two routes, namely, (a) the tegmen tympani and antri, and (6) 
the squamous portion of the temporal bone. In some cases both routes 
should be employed, especially if the abscess is located high above the 
tegmen tympani and contains large masses of debris and broken-down 
brain substance which cannot be removed through the perforation in the 
tegmen. In those cases in which the abscess is located near the tegmen 
tympani (roof of the cavum tympani) and in which the contents of the 
al)scess are purulent or fluid, the route through the enlarged perforation 
in tiie tegmen may prove adequate for the drainage. 



THE SURGERY OF BRAIN ABSCESS 



825 



Drainage through the Tegmen Tympani.— (a) A preliminary 
radical mastoid operation is first performed, not only to cure the 
mastoiditis and otitis media, but to expose the tegmen, or roof of the 
cavum tympani, the atrium of the brain infection. 

(b) The middle-ear cavity (cavum tympani) is mopped with a cotton- 
wound applicator to free it of pus and blood, and if necessary adrenalin 
chloride solution should be applied to check the hemorrhage. 




The incisions far brain abscess, ab, the primary mastoid incision; cc, the secondary mastoid 
incision; erf, an extension of the secondary incision for cerebeHar abscess; e/, the incision for 
abscess of tlie temporosphenoidal lobe of the cerebrum. 



(c) The tegmen tymj)ani sliould then be inspected under strong re- 
flected light for oozing pus, and for the dehiscence or perforation result- 
ing from necrosis. A probe may also be used to explore for rough and 
necrosed bone. 

(d) Having locatcti the |)()int from wliicli ])iis oozes, or the granulations 
protnuk* from the necrosed area of the tegmen, it should be gently 
cin-etted to remove the granulations, and to expose the necrotic bone 
and the perforation through it. 'J'lie opening should be enlarged by 
removing all the necrosed bone (Fig. 4.').") M, ;i dull en id (e being used for 
the purpose. 

(e) If the abscess is located nc;ir (he (loor of tlic middle fossa imme- 
(h'ately over the perforation in (he (cgmcn (yinj)aui it may be readily 



826 THE EAR 

drained through this enlarged opening. The dura and brain substance 
may be incised to enlarge the channel of communication between the 
abscess cavity and the cayimi tympani. In one case coming under the 
author's observation the abscess cavity extended into the brain substance 
for the distance of one and one-half inches, and communicated freely 
^vitll the ca%aim tympani. Large cholesteatoraatous masses were ad- 
mixed with the pus, and they were readily removed through the tegmen 
opening. 

ij) If the abscess is acute, simple drainage and irrigation are usually 
quickly followed by complete recovery. If the abscess is chronic, and the 
walls are lined with necrotic sloughs of brain substance, the healing 
process is much prolonged and requires careful after-treatment. 

Drainage through the Squamous Plate. — The drainage of cerebral 
abscess through the squamous plate of the temporal bone is indicated 
when (a) the opening through the tegmen tympani is not large enough 
to ensure adequate drainage; (h) when the abscess 
Fif^' 457 is located high in the brain substance, and only 

communicates with the perforation in the teg- 
men through a small fistulous tract; and (c) when 
the necrotic or cholesteatoraatous raasses are too 
large to escape through the tegmen opening, or 
are inaccessible through the tegmen tympani. 

Technique. — (a) It is presumed, if the abscess 
is of otitic origin, that the radical mastoid 
operation has been performed. The skin in- 
cision should be extended from the postauricu- 
lar mastoid incision in a curved direction back- 
ward, upward, and then forward, as shown in 
Circular trephine. Fig. 456 cf. The flaps are then elevated and re- 

tracted with the periosteum. 
(6) A circular plate of bone one-half inch in diameter is then removed 
from the squamous portion of the temporal bone (Fig. 455 a), with a circu- 
lar trephine (Fig. 457). The centre pin of the trephine should be located at 
a point one inch above the posterior wall of the meatus within the square 
area shown in Fig. 45.S, As the bone is of unequal thickness, one section of 
the circle may be penetrated before the others. The centre pin should be 
set one-eighth of an inch flush with the plane of the teeth of the trephine, 
as this is the average thickness of the squamous plate in this region. The 
trephine should be removed from time to time, and a sraall probe intro- 
duced into all parts of the circular cut to remove the bonedust, and to 
determine if the bone has been cut through at any given point. If it has, 
the trephine should be slightly tilted, so as to cut only at the intact por- 
tions. When the entire button of bone is severed from its attachments a 
thin elevator or spatula should be inserted into the cut and the button 
gently lifted from the dura. The button of bone should be wrapped in a 
piece of sterile gauze and placed in a sterile or antiseptic solution ready 
for reinsertion should it be needed — that is, if pus is not found. 

{c) Inspect the exposed dura for the following conditions: (1) The 




THE SURGERY OF BRAIN ABSCESS 



827 



presence of pus from an associated meningitis. (2) The presence of con- 
gested and infiltrated membranes. (3) The presence of brain pulsation. 
Brain pulsation is usually present when the abscess is large and deeply 




Kronlein's landmarks, hh, the German horizontal line, or Read's base line, extending front 
the lower margin of the orbit to the occipital protuberance; a a, the upper horizontal line extends 
from the supra-orbital margin parallel with the German line. A e, the anterior vertical line, ex- 
tending upward from the middle of the zygoma at right angles to the German line b b; d, the 
middle vertical line passes through the condyle of the inferior maxilla at right angles to the Gennan 
line bb; cc, the posterior vertical line extends from the posterior margin of the mastoid process 
at right angles to the German line bb. Af represents the location of the central fissure of 
Rolando; A g represents the fi.ssure of Sylvius; A B represent tlie points for trepliining to 
evacuate blood from a ruptured middle meningeal artery. Von Bergmann's area is enclosed witliin 
the square outlined by the heavy, black lines. Otitic abscess and abscess of the temporal lobe 
may be drained through this area. The upper line of the square represents the area for tapping 
the lateral ventricle. cB, (he sigmoid portion of the lateral sinus; h, the point for entering the 



located in the l)raiii substance, or when the iil)scess is small Jiiid snj)or(icia]. 
'J'he absence of piil.sation may, therefore, be taken to indicate a small 
deep-seated pus cavity or a large superficial one. Leptomeningitis with 



828 



THE EAR 



pachyiiieiiingitis may result in the fusion of the meningeal membranes, 
and thus obscure the pulsations which would otherwise be present. 

(d) The dura should be incised layer by layer near the centre of the 
opening until its entire thickness is penetrated. It should then be seized 
with forceps, lifted from the underlying structures, and incised the whole 
diameter of the opening. If necessary, a cross-incision may be made to 
overcome the tension. The bloodvessels crossing the field should be cut 
one at a time, pinched with artery forceps, and ligated if necessary, as 
the blood might otherwise penetrate between the membranes and produce 
pressure, or carry infection to other parts. 

(e) The exposed membranes, brain substance, and bone edges should 
be dusted with iodoform powder to protect them from the infected pus 
when the abscess is opened. 

Fig. 459 




ASTOID CELLS 



'EUSTACHIAN TUBE 



A transparent skull showing the relation of the sutures, ventricles, Eustachian tube, tympanic 
cavity, mastoid cells, and lateral sinus of the left side of the head. 

' ' (/) The choice of an instrument for opening the abscess, or for explor- 
ing for it, is a matter of some importance. A hollow needle or cannula has 
commonly been chosen for this purpose. The late Christian Fenger 
preferred a long, slender-bladed scalpel, as it inflicted less damage to the 
brain substance, and at the same time was superior in locating and evacu- 
ating the pus. The needle and cannula are objectionable on account of 
the brain substance entering their lumen when suction is applied, thus 
interfering with the detection and withdrawal of the pus. 

The knife should be passed a distance of one inch into the brain sub- 
stance, then slightly rotated and lifted to open the channel for the dis- 
charge of the pus. If pus does not appear, it should be introduced a 
half inch farther and similarlv rotated and lifted. The knife should be 



THE SURGERY OF BRAIN ABSCESS S29 

introduced to a greater depth than this with great caution, as the lateral 
ventricles (Fig. 459) may be opened and exposed to infection. If pus is 
not thus found, the knife should be withdrawn and reinserted in another 
plane, and if necessary in several planes, until the abscess is located and 
evacuated. If care is taken to keep the exposed area of the surface of the 
brain and the knife surgically clean, there is but slight danger from this 
method of procedure, even when several punctures are made. The parts 
of the brain thus incised are not functionally injured, as the incision is 
clean cut, and the instrument is sterile. 

(g) If the pus is too thick to flow readily through the incision, or the 
necrotic sloughs of brain substance are too large to pass through the 
incised channel, the encephaloscope designed by ^^liiting should be 
used. It should be introduced over the blade of the knife while it is 
still in the brain, the blade acting as a guide to the abscess. Through the 
opening thus obtained the pus will readily flow, and the sloughs may be 
removed. A^Tien the abscess cavity is emptied its walls may be inspected 
by the aid of reflected light. If they are necrotic they should be curetted 
until healthy brain substance is exposed. Should such material be left 
in the cavity, the infection and inflammation will be much prolonged. 
Whiting's encephaloscope affords a means of treatment of great advan- 
tage that should be utilized whenever the conditions present warrant it. 

(h) The abscess cavity should be irrigated with a warm antiseptic 
solution until the return flow is clear. With WTiiting's encephaloscope 
or brain speculum the irrigation is a simple matter, as it allows the nozzle 
of the syringe to be introduced and at the same time allows the fluid to 
make its exit into the pus basin. If the encephaloscope is not used, a 
cannula should be introduced, the lumen of which is larger than the one 
attached to the syringe, to prevent the possibility of becoming plugged. 
This provision is necessary, as, if the outflow of the irrigating solution is 
blocked, the pressure of the retained fluid may cause it to extend beyond 
the walls of the abscess cavity to other parts of the brain. 

(i) The first dressing should consist of a drainage wick of gauze, a 
protective covering of antiseptic powder, and an outer absorbent gauze 
pad. The drainage wick should extend to the outer wall of the cavity 
and should come in contact with the external absorbent gauze pad. The 
proximal end of the gauze wick should be folded over the bony wound 
and dusted with a mixture of iodoform and boric acid (1 to 5), to prevent 
adhesion between the gauze wick and the outer absorbent gauze pad, 
as it may be necessary to leave the gauze wick in position for several 
days; whereas the outer gauze ])ad may, and in many instances should, 
be removed daily. In acute cases the walls of the abscess cavity may 
(•()lla])se and Iical in a day or two. Chronic cases will require several 
(lays or weeks to hciil. Macewen reconnnends that in some acute cases 
only the outer gauze pad be used, and if there is no temj)erature or pain, 
that it be left undisturbed for three weeks, the obvious purpose being to 
avoid the possibility of infecting the wound by removing the dressing. 
When, however, the discharge is sufficient to soil the outer gauze pad, it 
should be rcnioNcd (lail\- iin(il hcaliiii;- is coinplclcd. 



830 THE EAR 



THE SURGERY OF CEREBELLAR ABSCESS. 

There are three routes available for evacuathig abscess of the cere- 
bellum, namely: (a) Through the mastoid wound via the recess at the 
angle of the sigmoid knee (Fig. 455 c), that is, through the recess between 
the inner wall of the antrum and the knee of the sigmoid sinus; (6) through 
the inner wall of the sigmoid sinus when the vessel s thrombosed and 
has been exenterated; (c) through the skull one and one-fourth inches 
posterior to the meatus, and below the level of the lateral sinus (Fig. 
455 d). 

(a) If the abscess is immediately behind the petrous pyramid of the 
temporal bone it may be easily reached through the mastoid wound 
via the recess between the knee of the lateral sinus and the antrum. 

{b) If the lateral sinus is thrombosed (and it is often the source of the 
cerebellar abscess), its walls should be carefully searched for necrotic 
areas, not alone as an avenue of approach to the abscess, but as a 
means of tracing the location of the abscess through the fistulous tract 
leading from the sinus to the abscess cavity. This route may be utilized 
to evacuate the abscess, though the subsequent treatment through this 
route is difficult to carry out on account of the contracted and deep situa- 
tion of the opening in the mastoid wound. This is also true of the first 
(a) route. 

(c) The external route through the skull (Fig. 455 d) is generally 
preferable on account of its accessibility. 

The technique of the operation is otherwise similar to that described 
for cerebral abscess. 



THE SURGICAL TREATMENT OF SEROUS MENINGITIS. 

Serous meningitis has no characteristic symptoms by which it may be 
positively diagnosticated from purulent meningitis. If, however, after 
completing the radical mastoid operation the tegmen tympani or antri 
is opened and serous fluid escapes, and the meningeal symptoms sub- 
side, the diagnosis of serous meningitis may be made (Fig. 455 h c). 

The surgical treatment consists in removing the tegmen tympani or the 
tegmen antri and allowing the serous effusion to escape. The after-treat- 
ment consists in the usual mastoid dressings. 



THE SURGICAL TREATMENT OF EXTRADURAL ABSCESS OR 
PACHYMENINGITIS CIRCUMSCRIPTA. 

Circumscribed pachymeningitis, or extradural abscess, located over the 
tegmen tympani or antri in the middle fossa of the skull, may be success- 
fully treated in nearly all cases by first performing the radical mastoid 
operation, and then removing the roof of the cavum tympani or the roof 



SURGICAL TREATMENT OF THROMBOSIS OF LATERAL SINUS 831 

of the antrum, and evacuating the purulent secretion. An extradural 
abscess is a localized meningitis, the circumference of which is walled 
off by a plastic exudate. 

The early operation upon these cases prevents the spread of the infec- 
tion in the form of a brain abscess and leptomeningitis, which are more 
serious affections. Leptomeningitis is usually fatal, though a few cases 
have recovered under surgical drainage. 



THE SURGICAL TREATMENT OF THROMBOSIS OF THE 
LATERAL SINUS. 

Infective thrombus is more often found in the sigmoid portion of the 
lateral sinus than in any other of the intracranial sinuses. Early recog- 
nition and surgical treatment is of the greatest advantage to the patient, 
as many cases thus early recognized and treated recover. 

Technique. — (a) A preliminary mastoid operation is performed. If 
the mastoiditis and otitis are acute, it may be only necessary to do a 
simple mastoid operation, the cavum tympani being unmolested; if, 
however, the mastoiditis or otitis are chronic, and if the labyrinth is 
involved by the infective process, the radical mastoid operation should 
be performed. Richards reports 11 cases of labyrinthine disease upon 
which he operated, performing more or less extensive exenterations of 
the labyrinth, of which three were affected by thrombosis of the lateral 
sinus. This, as he says, points strongly to the labyrinth as a possible 
atrium of infection (Figs. 368 to 398, and the technique of the mastoid 
operations). 

(b) Remove the cortex of dense or necrosed bone covering the mastoid 
aspect of the lateral sinus as extensively as possible, thus exposing the 
membranous sinus to observation and operation. Determine whether 
a perisinuous abscess (extradural abscess of the sinus) is present. Note 
the texture of the membranous sinus, whether velvety, covered with 
granulations at certain points, or necrosed. Palpate it with the finger to' 
determine its resistance, whether doughy, hard, or fluid. Some surgeons 
recommend that the sinus be exposed in every mastoid operation, and that 
a portion of its contents be withdrawn with a hypodermic needle to ascer- 
tain if pus is present. This is reprehensible practice, as it is an unreliable 
method of determining the ])resence of pus, and exposes the sinus to the 
danger of infection. Wiiiting recommends that the tip of the finger be 
placed as near the jugular i)ull) as possible and then drawn upward 
toward the knee, and noting wlietlier the stripped siinis relills below the 
finger. If it does, the jugular bulb is open. The sinus should then be 
stripped from above downward toward the juunl.ir bull), and the same 
observation made of the uj)per portion of the sinus. It' il icfills, the sinus 
is open a))ove; if it does not, it is closed by a Ihiouibus. Il;i\ing dclci- 
mined to open tiie membranous sheath of the sinus, see that iuiluform and 
boric acid })owder (1 to 5) and a strip of iodoform gauze (1 x 24 in.) are 
in readiness in case free hemorrliage occurs. 



832 



THE EAR 



(c) Incise the whole lengtli of tlie exposed ])ortion of tlie membranous 
sinus (Fig. 4G0), and if the hemorrhage is free it should be closed by turn- 
ing in the cut edges of the membrane and packing the bony opening with 
the strip of iodoform'' gauze. A few moments of hemorrhage should be 
allowed, as it may wash out the infective material and lead to recovery. 

If the incision is not followed by hemorrhage, the thrombic clot, 
whether it be solid or undergoing disintegration, should be removed 
with a dull curette. The portion of the clot near the jugular bulb 
should be curetted until blood appears at the lower end of the opening. 
The curette should then be passed upward through the knee of the 




Thiumbus of the lateral sinus exposed. 



sinus, and the clot removed from this part of the sinus. The flow 
of blood from this end of the sinus is evidence that this portion has been 
cleared of the thrombus. Both ends of the sinus should give forth 
l)lood. The lower or jugular end of the sinus should be kept closed 
with the finger while the upper end is being curetted, as too much 
blood might otherwise be lost, or the surgeon be impelled to work in 
unseemly haste. Having cleared the sinus of the clot, it should be filled 
with the iodoform boric acid })owder, the edges of the membrane turned 
in and the bony aperture filled with iodoform gauze, and the usual mastoid 
drainage and al)sorbent dressing applied. 



RESECTION OF THE INTERNAL JUGULAR VEIN 833 

(d) The dressing may be removed at the end of from twenty-four to 
forty-eight hours, and the gauze removed from the bony aperture of the 
lateral sinus without danger of hemorrhage. 

(e) The after-treatment consists in the usual mastoid dressings here- 
tofore described. 

Should pain, chills, and a rise in temperature occur, the dressings 
should be removed at once and the parts examined to determine the con- 
ditions which gave rise to the symptoms. If pus is present, endeavor to 
trace it to its source. It will usually be necessary to reopen the sinus and 
extend the curettement, as the sepsis is probably from within the sinus, 
fragments of the thrombus having probably been left at the time of the 
primary sinus operation. The sepsis may, however, have its origin from 
a perisinuous abscess. It may become necessary to resect the jugular vein 
and the jugular bulb. 

RESECTION OF THE INTERNAL JUGULAR VEIN. 

The indications for the ligation and resection of the internal jugular 
vein are as yet not fully established. It is still a question as to when 
the resection increases the danger of spreading the infection, and when 
it prevents spreading the infection from a thrombosed lateral sinus. 
If the internal jugular vein is ligated and resected, the anastomotic 
channels, of which there are many, will receive the venous blood cur- 
rent, provided there is a flow of blood through the sinus. If only the 
lower portion of the lateral sinus is closed by an infected thrombus, 
the blood may be forced into the superior petrosal sinus and cause 
thrombosis in it and the cavernous sinus, with which it communicates. 
If the entire sigmoid portion of the sinus is blocked by a thrombus, the 
blood current may be forced backward into the superior longitudinal sinus. 
If the thrombus is limited to the jugular bulb the blood current may be 
forced into almost any or all of the intracranial sinuses. In ligating the 
internal jugular vein the effect upon the blood current is the same as that 
in jugular bulb thrombus. The question as to when the jugular vein 
should be ligated and removed from the neck resolves itself into the con- 
sideration of the foregoing facts, and may be stated as follows: 

(a) It may be ligated and removed when the entire sigmoid sinus is 
thrombosed and obliterated by operative procedure. The jugular vein 
should be removed first, however, to obviate the danger of disseminating 
particles of the thrombus which may become detached during the exen- 
teration of the sigmoid sinus. 

(6) The internal jugnlar vein may be ligated and removed when the 
jugular bulb is tlinjinbosed, the jugular bulb being removed after the 
resection of the vein, provided the sigmoid an<l lateral sinuses are entirely 
free from infection, or tliat (lie sigmoid sinus is ol)literate(l at the same 
time, whether it is infected oi- not. If the sigmoid sinus is leftoj)en, the 
infective material from the juguhii- bulb may be forced backward through 
the sigmoid siinis, and IVom thence (hrough (he petrosal to the cavernous 
sinuses. 
.53 



834 THE EAR 

(c) The internal juonlar vein may be ligated and resected when it is 
thrombosed by extension from a similar condition in the sigmoid sinus 
and jugular bulb. 

{d) The jugular vein should not be ligated and resected when there is a 
flow of blood through the sigmoid sinus. 

(e) In a general way it may be said that the jugular vein may be 
ligated and resected when the sigmoid sinus is completely blocked with 
an infected thrombus. 

The object of the ligation and resection of the internal jugular vein is 
to prevent the dissemination of the infection to other parts of the body, 
as the lungs, spleen, liver, kidneys, intestines, etc. Statistics show more 
favorable results when this is done in complete blockage of the sigmoid 
sinus; and, on the contrary, the results are worse when the sigmoid sinus 
still has a current of blood passing through it. 

Technique. — (a) Extend the mastoid incision downward along the ante- 
rior border of the sternomastoid muscle to the sternal notch (Plate XIII). 

(6) Retract the sternomastoid muscle backward and separate the 
fascia and other structures by blunt dissection mitil the internal jugular 
vein is exposed. 

(c) The pneumogastric nerve runs between the internal jugular vein 
and the carotid artery, and should be respected. 

{d) Ligate the internal jugular vein just above the sternum and just 
below the floor of the external auditory meatus (Plate XIII). 

{e) Ligate all the branches of the vein given off between the upper and 
lower ligations of the jugular vein (Plate XIII). 

(J) Sever the jugular vein just above the lower and just below the upper 
ligatures. Then sever all the branches close to the jugular vein, and 
remove the vein from the neck. A gauze pad shoukl be placed under the 
vein before resecting it to protect the tissues from infection. 

(f/) The sigmoid sinus is next opened and the thrombus removed as 
described in the preceding section. The danger of disseminating the 
disintegrating thrombus through the jugular vein is largely obviated by 
its removal, though the anastomotic communications are not altogether 
obliterated. 

(h) The sigmoid sinus should be packed and obliterated (Plate XIII), 
and the mastoid wound dressed as previously described, with the exception 
that the lower half of the mastoid incision is left open so that the region of 
the exenterated sigmoid sinus may be subsequently inspected and dressed 
through it. The incision in the neck should be closed throughout its 
entire length, a secondary incision being made one inch posterior to the 
lower angle. This incision should be made to communicate with the 
primary neck wound by tunnelling beneath the skin. A spiral tube with 
a small wick of gauze in it should be introduced into the secondary inci- 
sion, and be extended beneath the skin to the lower portion of the primary 
neck wound, as shown in Fig. 434. The object of the secondary incision 
is to prevent an inisightly scar. As the primary wound was occupied 
by an infected and thrombosed vein, the tissues may have become con- 
taminated. Under these circumstances, if the tube dressing were intro- 



PLATE XIII 




The Combined Operation for the Rennoval of a Tlirombosed 
Sigmoid Sinus, Jugular Vein, and Jugular Bulb. 

The sigmoid portion of the lateral sinus has been exenterated and packed with gauze. The 
jugular vein and its branches have been ligated and severed, and the floor of the meatus is 
being removed with a Gigli saw to expose the jugular bulb. The facial nerve has been exposed 
and retracted forward with a gauze tape to permit the hone which encloses it to be removed, as 
it is in the operator's pathway to the jugular bulb, though this was not necessary in this par- 
ticular dissection. 



PLATE XIV 




The Anatomy of the Grunert-Panse Exposure of the Jugular 
Bulb. Grunert removes the tip of the mastoid process and 
then proceeds to>A/^ard the jugular foramen at the base of the 
skull. When the jugular foramen is reached he removes the 
outer and posterior portion of the bony ring encircling the 
vein. As shown in the dra^A^ing, the facial nerve lies in the 
way. Panse exposes it, removes it from its canal, displaces 
it for\A^ard, and proceeds to expose the jugular bulb. 



1, Tympanic cavity; 2, malleus; 3, incus; 4, posterior semicircular canal; 5, saccus endolymphaticus; 
6, mastoid emmisary vein; 7, lateral sinus; 8, occipital vein; 9, spinal accessory nerve; 10, facial nerve. 
(After Bardeleben.) 



THE SURGERY OF THE JUGULAR BULB 835 

diiced into the wound through the primary incision, the tissues around the 
tube dressing would heal slowly and cause a retracted and disfiguring 
scar. The secondary incision, being removed from the region of infec- 
tion, will, after the tube is discontinued, heal quickly and with little scar 
and disfigurement. 

(h) The after-treatment, in so far as the wound in the neck is con- 
cerned, consists in the removal of the drainage tube dressing at the end of 
the third day, or earlier if pain and temperature arise and persist. In 
those cases in which the neck wound was not infected the tube dressing 
may be dispensed with after the first dressing, a small gauze wick being 
inserted only a little distance into the wound to carry away the excess of 
secretions. The channel occupied by the tube will quickly fill by granu- 
lation, and at the third dressing the gauze wick may be omitted to 
allow the cutaneous edges of the incision to approximate and unite. The 
scar resulting will be slight and the cosmetic effect good. 

The sigmoid and mastoid wounds should be dressed as previously 
described. 

THE SURGERY OF THE JUGULAR BULB. 

The indications for the removal of the jugular bulb are (a) extensive- 
necrosis in the region of the bulb; (b) severe systemic infection from the 
disintegrating thrombic clots ; and (c) the desire to remove every vestige 
of the foci of infection in order to give the patient the greatest chance of 
recovery. 

Technique. — (a) The mastoid operation is first performed as pre- 
viously described. The simple mastoid operation is performed if the 
case is acute and there are no special indications, as labyrinthine sup- 
puration and necrosis, for opening the cavuni tympani. Cerebral abscess 
with the atrium of infection through the tegmen tympani, and sigmoid 
sinus thrombosis with the atrium of infection through the labyrinth, 
etc., necessitate the performance of the radical mastoid operation. 

(b) The internal jugular vein is next resected as described in the 
preceding section (Plate XIII). 

(c) The sigmoid sinus is exposed, exenterated, and packed with 
gauze (Plate XIII). 

(d) The floor of the external auditory meatus is removed, as it is in the 
pathway to the bulb (Plates XIII and Xl\). 

(e) The facial nerve is exposed as recouHiiciided by Pause, as i( otteii 
lies in the pathway to the Inill). The nerve should be hflcd IVoui its 
exposed canal, a strip of gauze passed aroiuid it, widi w hich it is i-cti'aclcd 
anteriorly, as shown in Plates Xlll aud XI\\ 

(f) The styloid process, togi'dicr wilh Hie lower poi'liou of the boue 
which previously supported the facial ueive. aud that poi'tiou of the 
mastoid tip whicli ol.->l|-uel> the path to the l.ulK, should I.e reiu(.ve<l 
with a eliisel, boue forcej)s, or a < iiuli saw, as show u in IMale Xlll. The 
saw should be placed in front of the fi-agiueul of the (looi- of the uieatus, the 
anterior wall haviuu' been nivxiouslv I'euioved. ( )ue eud slioidil l)e passeil 



836 



THE EAR 



backward beneath the tip of the mastoid process (the sternomastoid 
muscle being partially severed, (Plate XIII), and the other backward and 

Fig. 461 Fig. 462 







Fig. 461. — The first step of the Mosetig-Mooihof plastic operatiou for the closure of a persisletit 
retro-auricular opening. 

Fig. 462. — The second step of the Mosetig-Mooihof plastic operation. 

Fig. 463. — The third step of the Mosetig-Moorhof plastic operation for the closure of a persi.-itent 
retro-auricular opening. 

Fig. 464. — The fourth ste|) of the Mosetig-Moorhof plastic operation for the closure of a per- 
sistent retro-auricular opening. 



over it, and the bone, including the styloid attachment and the anterior 
portion of the mastoid tip, sawed through (Plates XIII and XIV). The 



PLATE XV 




The Exposure of the Jugular Bulb Completed, the Sigmoid 
Sinus Exenterated and Packed ^A'ith Gauze, and the Facial 
Nerve Lifted from its Canal and Retracted Anteriorly. The 
facial ridge is usually located more anteriorly over the jugular 
bulb than shown in the dravr/^ing. 



THE SURGERY OF THE JUGULAR BULB 



83i 



remaining portion of the bone, especially that lying beneath the floor of 
the meatus, may be removed with bone forceps. 

(^f) If the transverse process of the atlas projects outward -into the 
field of operation, it should be removed, care being exercised to avoid 
injuring the vertebral artery (Bardeleben). 

(h) The outer portion of the thin bone encircling the jugular bulb 
should be removed with bone forceps. 

(i) The jugular bulb, being exposed to surgical interference, should be 
examined, and its condition noted for scientific purposes. As the sig- 
moid sinus above and the internal jugular vein below have already been 
obliterated and removed, there is no added danger in removing the bulb 
which forms the connecting link between them. 




Fig. 465. — The second step in the Passow-Tiautmann plastic- opeiutiijn for the closure of a 
persistent retro-auricular opening. The sutures a h and c d arc to be tied lo the opposite sutures 
to bring the periosteum together. 

Fig. 466. — The third step of the Passow-Trautmann plastic operation. Closing the skin. 

(j) The jugular bulb should be removed from the juguhir fossa with a 
curette. 

{k) The primary dressing should consist of a gauze wick, the distal 
end of which is inserted into the jugular fossa, and tlie proximal end in 
contact with the external ab.sorbent dressing. The mastoid, sigmoid 
sinus, and neck wounds should also be drained by si)iral (iilics with a 
small gauze wick in the lumen of the tubes. 

it) The after-treatment consists in api)lying .suKablr internal (h-ainage 
and external ab.sorbent dressings until all sii|)])nration c-ea.ses and the 
cavities have healed. 'J'he mastoid wound should heal by gramilation, 
finally becoming covered with ei)i(lermis. Should exuberant granula- 
tions'form, they should be reduced with caustic applications or witii 



83S THE EAR 

the electric cautery. Should the mastoid bony surfaces fail to heal 
within from four to ten weeks, they slioidd be more freely exposed (the 
postauricular woiuid is left open at the time of the primary operation), 
curetted, the hemorrhage checked, and Thiersch grafts applied as pre- 
viously described. 



CLOSURE OF POSTAURICULAR FISTULA. 

The Mosetig-Moorhof Method.— This method is adapted to the 
closure of small openings, and is performed as follows: (a) The edges of 
the fistulous openings are freshened; (b) a skin flap corresponding in 
size with the opening is made below the opening, a pedicled attachment 
being left at the u])])er portion of the flap; (c) the flap is then turned 
upward and placed in the fistulous opening, with the skin surface inward; 
{cl) it is then fixed in this position by four sutures; (e) finally, the fresh- 
ened edges of the fistulous opening are brought together over the raw 
surface of the skin flap, thus forming an epithelial lining on the inside as 
well as on the outside of the fistulous opening (Figs. 4()1, 462, 463, 464). 

Passow-Trautmann Method.— («) Make a circular incision about 
one-eighth inch or more (Trautmann) from the edge of the fistulous 
opening, and separate the periosteum and skin within the incised circle 
from the bone beneath; (6) unite the everted margins of the periosteum 
thus loosened, with absorbent catgut sutures; (c) loosen the skin exter- 
nal to the incision and unite the edges over the first periosteal flaps with 
sutures (Figs. 465 and 466). 



CHAPTEE XLIX. 

FACIAL PARALYSIS. 

The Plastic Surgery of the Facial and Hypoglossal Nerves.— The 
facial nerve is subject to the same diseases as other peripheral nerves, 
the most frequent affection being paresis or paralysis. 

Paralysis is characterized by facial deformity, due to the immobility 
of the muscles supplied by the facial nerve. The manifestations are the 
inability to raise the eyebrow, the 

skin of the forehead, lip, or cheek, Fig. 467 

and to completely close the eye. 
The attempt to distend the buccal 
cavity is attended by the escape of 
air through the paralyzed side of the 
mouth. There is also inability to 
pucker the lips in whistling, because 
the angle of the mouth droops. 
The drooping causes the patient a 
certain embarrassment in speech 
(Fig. 467). 

Etiology. — 1. Exposure to cold 
and wet, followed by neuritis and 
perineuritis of the facial nerve. 

2. A neuritis due to toxemia, 
syphilis, rheumatism, diabetes, gout, 
leukemia, diphtheria, and other in- 
fectious diseases. 

3. Tumors affecting any part of 
the course of the facial nerve, as intra- 
cranial, intra-osseous, and external 
neoplasms. _ _ i,.^,,^, ,.,„,,i,.,i, „f „,;,;, .,,)«;„. tuo 

4. Traumatism is one of the most patient is attempting to close both eyes and 

frequent causes of facial paralvsis, to drkw the mouti. on both sides; the HKi.t 

1 1-1111 ' I facial nerve beiiiR paralyzed ho is uiKihlc in 

and one Whicll should concern the ^lose the right eye or to c.nii.nl il.c ilulu 

otologist. The facial paralysis may nncic of the mouth. 

arise during suppuration of (lie 

middle and internal car, csix-cially cliroMic suppuration, or sup|)u- 

ration persisting after o|)crati\c pi'ix'cchircs for ils cure. 

Facial ])aralvsis iua\- also i-csiill from |)a<'king tlic nia>loiil udiinil too 
tightly after a mastoid operation. I'aralysi> i- known lo li;i\-e l>een caused 
by the very means dc\i>cd I'oi' die pi-oicedon of die I'acial ncr\-e dui-ing 
an oDci-ation, nanicl\-, Stacke's prolcelor in llie hands of an inc\|ici-icnccd 




840 'i'lJE EAR 

assistant, who presses it too firmly against the facial canal or twists it 
while it is in the aditus ad antrum. 

Curettage of the middle ear for granulations, where the facial nerve is 
not covered by bone as it passes through the antrum, may injure the 
facial nerve and cause paralysis. 

The vigorous cauterization of granulations in the middle ear with 
chromic or other caustic acids may also produce facial paralysis. One 
such case came under my observation. 

Treatment. — The treatment is divided into: 

1. Medical (local and expectant). 

2. Surgical. 

In paralysis of toxic origin, following exposure to cold or infectious 
diseases, the paralysis is usually slight, recovery occurring in from one 
to six months by the natural process of repair. The usual treatment in 
such cases is elimination of the toxins by catharsis, the administration of 
strychnine and other tonics, facial massage, and electricity. These pro- 
cedures are used principally to keep up the muscular tonicity, while the 
nerve is regaining its normal function. Paralysis after a mastoid opera- 
tion from too firm packing, or violent reaction, usually subsides within a 
short time after the cause is removed. When a tumor is pressing upon 
the facial nerve, or the nerve is injured in the removal of the tumor, the 
paralysis will frequently disappear soon after the completion of the 
operation. 

In all other conditions causing facial paralysis, wherein the continuity 
of structure of the nerve has been destroyed for a greater distance than 
the process of repair will bridge over, a surgical operation is required to 
effect a cure. In order to understand the surgery of the facial nerve it is 
necessary to have a clear conception of its anatomy and physiology. 

The facial nerve arises from a large group of cells situated in the upper 
portion of the medulla oblongata near the junction of the medulla and the 
pons. 

From this nucleus the nerve passes up to the fourth ventricle, forming 
a knee, to the nucleus of the sixth nerve, and comes out at the junction of 
the pons and medulla in connection with the sixth nerve. The fibers of 
the facial lie on the inner side of this composite nerve. From this point the 
nerve passes through the internal auditory meatus, through the Fallopian 
canal, beneath the posterior and lower border of the annulus tympanicus, 
through the anterior border of the mastoid process, and then emerges from 
the stylomastoid foramen. From this point it passes forward into the 
substance of the parotid gland, within which it divides into three great 
branches, known as fes anserinus (goose foot). One branch goes to the 
muscles of the forehead, the eyelid, and the upper portion of the malar 
zygomatic region. The second branch passes across the face, supplying 
the angle of the nose and the muscles that raise the upper lip. The third 
branch supplies the muscle at the angle of the mouth, the lower lip, the 
platysma, and the stylopharyngeus muscle. 

At the exit of the nerve from the stylomastoid foramen one branch, the 
auricularis posterioris profunda, is given off, and goes to the muscles of 



THE SURGERY OF THE FACIAL NERVE 841 

the neck. The interosseous portion of the facial nerve gives off a 
number of small branches, communicating with other nerves, as the fifth 
and the pharyngeus. The pneumogastric and sympathetic also give off 
special branches, the petrosals, stapedius, and chorda tympani. 

The function of the nerve is to supply the muscles of expression, as 
mentioned above, and it is, therefore, a motor nerve. However, a certain 
amount of sensitive fibers are contained within it, due to its gross associ- 
ation with the other intracranical nerves. 



THE SURGERY OF THE FACIAL NERVE. 

The operative procedures for the cure of facial paralysis are: 

1. Suture of the severed ends of the facial nerve. 

2. Plastic operations. 

(a) The union of the facial and hypoglossal nerves. 

(b) The union of the facial and spinal accessory nerves. 

(c) The union of the facial and the glossopharyngeal nerves. 
The first procedure, that is, the suturing of the accidentally severed 

ends of the facial nerve, seems to be unnecessary, because, if only moder- 
ate loss of substance between the two ends exists, the proximal ends of the 
nerve will regenerate and unite with the distal end without suturing. 

In the plastic operations, the union between either the facial and spinal 
accessory or the glossopharyngeal, there are so many untoward symp- 
toms following the procedures (6) and (c) that they have been practically 
abandoned and the union of the facial and hypoglossal nerves (a) prac- 
tised instead. 

The Methods of Anastomosing the Facial and Hypoglossal 
Nerves. — 

1. End to end. 

2. End to side. 

3. Side to side. 

The easiest method is the end-to-end operation, and it is the most 
productive of success, but it necessitates paralysis of the muscles of 
the tongue. The end-to-side operation is to be preferred in all cases, 
as paralysis of the tongue is avoided. The side-to-side procedure has 
only been jK-rfornied once, and with a ])()()r result. 

Plastic Surgery of the Facial and Hypoglossal Nerves; Anasto- 
mosis of the Facial and Hypoglossal Nerves. — Technique. — (a) General 
anesdie.sia, the patient liaviiig been |)rc|)ai'c<l as for any other major 
operation. 

(b) An incision of the skin should be made, beginning at the tij) of the 
mastoid process, near the lobe of the auricle, and extending downward 
and forward along the anterior border of the sternomastoid muscle to 
the level of the cricoid cartilage of the larynx. 

(c) It should then be carried through the superficial fascia and the 
platysma muscle, thus exposing the sternomastoid muscle. The external 
jugular vein is usually sacrificed in this j)rocedure, the severed ends 
beiuir tied. 



842 THE EAR 

(d) The anterior border of the sternoraastoid muscle and the internal 
jugular vein sliould be located, and retracted posteriorly, to expose the 
hypoglossal nerve, as shown in Plate XVI . The posterior belly of the 
digastric muscle is located more anteriorly and superiorly, as it extends 
from the mastoid tip to its pulley. 

(e) The dimensions of the parotid gland, which is situated on the pos- 
terior border of the ramus of the inferior maxilla, should be determined 
as the facial nerve divides into three branches within its substance. 
Having located the boundaries of the parotid gland, trace the facial nerve 
to it. The facial nerve may then be traced backward and upward to its 
exit from the stylomastoid foramen. 

(J) The hypoglossal nerve should then be isolated from the tissues 
covering it. It crosses the external carotid artery just below^ the point 
wdiere the occipital artery is given off. The nerve should be exposed by 
blunt dissection as far posteriorly as possible, to free it from the tissues, 
so that it may be brought toward the stump of the divided facial, with 
which it is to be anastomosed. 

(g) The facial nerve should then be drawn from the Fallopian canal 
as far as possible, and severed at the stylomastoid foramen. If it is not 
thus drawn from the canal it will be so short as to render the anastomosis 
difficult or impossible. 

J. C. Beck has recently dissected the facial nerve from its bed in the 
Fallopian canal, a procedure which gives more latitude for stretching it 
so as to meet the hypoglossal nerve. 

Having severed the facial nerve, the sheath covering its proximal stump 
should be removed with scissors to expose its axis cylinders (Fig. 4()8). 

(i) Make an incision one-eighth inch long in the sheath of the hypo- 
glossal nerve, in as close proximitv to the stump of the facial nerve as 
possible (Plate XVI). 

(j) The nerve fibers should then be separated with fine pointed dis- 
secting forceps, so that when the barred axis cylinders of the facial stump 
are inserted into the hypoglossal incision they will be in direct contact 
with those of the hypoglossal nerve. 

(k) A fine silk thread with a small round needle on either end should 
then be passed through the sheath of the facial nerve from without 
inward, and each needle passed through the sheath of the hypoglossal 
nerve from within the incision outward. The same procedure is then 
carried out on the opposite side of the facial nerve, as shown in Fig. 468. 

(/) The operator and the first assistant each handle one suture, and 
draw it tight, while the second assistant separates the lips of the incision 
in the hypoglossal nerve, the third assistant guiding the pointed stump 
of the facial into the hypoglossal incision. 

The anchor sutures (Fig. 4(39) are then tied. The axis cylinders of the 
two nerves are thus brought into direct contact. 

The stump of the facial nerve should be directed toward the proximal 
end of the hypoglossal nerve, so that stimuli from the brain, coming 
through the hypoglossal, will be more readily transmitted to the facial 
nerve and carried to the muscle of facial expression. 



PLATE XVI 




The Anastomosis of the Facial \A^ith the Hypoglossal Nerve. 
(I, the parotid gland; b, the stump of the facial and the facial 
anastomosed v/ith (g) the hypoglossal nerve ; c, the posterior 
belly of the digastric muscle; rf, the external jugular vein; 
e, the sternomastoid muscle retracted to expose the hypo- 
glossal nerve; f, the omohyoid muscle; </, the hypoglossal 
nerve; m, the mastoid process. 



THE SURGERY OF THE FACIAL NERVE 



843 



The sutures should be tied with the greatest care. If too great a num- 
ber of the axis-cyhnder fibers of the hypoglossal are caught in the suture, 
there will be a certain amount of paralysis of the tongue (Fig. 469) . 



Fig. 468 




Sohema showing the method of suturing tiie fascia of the facial with the hypoglossal nerve. 
a b and c d, double-needled anchor sutures. 

Too great a tension of the hypoglossal nerve will also result in lingual 
paralysis, hence the necessity of drawing the facial from the Fallopian 
canal, and dissecting the hypoglossal nerve as far posteriorly as possible, 
to give it greater freedom of displacement toward the stump of the facial 
nerve. 



bb, anchor sutures holding tl 
a a, a loose running sut 




he hypoglossus nerve; 
lypoglossns nerve. 



(in) A secondary continuous .suture .slionl 
lips of the hypoglossal iiu-ision, ;is shown i 
should not be tied, but drawn liglidy. 



tlicu be pas.sed through the 

l""io-. tCi!) (I (I. This siifiirc 



™ 



844 



THE EAR 



I 



(n) The anastomosed nerves should be covered by a piece of cargile 
membrane, and the muscles of the neck replaced in their normal positions 
over the nerves. This prevents the formation of scar tissue and adhesions, 
which would greatly interfere with the success of the operation. 

(o) The final step of the operation consists in suturing the superficial 
fascia and skin, drainage being unnecessary as the operative field is aseptic. 

After-treatment and Observations. — The skin stitches should be removed 
in from five to seven days, and as soon thereafter as possible, massage 
and electric and tonic remedies should be instituted. 

The earliest manifestations of the proper union of the nerves is the 
appearance of a certain amount of tonicity in the muscles of the paralyzed 
side of the face. This change is only an indication that anatomical union 




Partial lingual paralysis shown upon protrusion of the tongue, due to tlie injury of a few of the 
fibers of the hypoglossus nerve at the time of the union of the facial and tlie hypoglossus nerves. 
a, the area paralyzed. (Dr. J. C. Beck's case.) 



has occurred, and should not be construed as a beginning of functional 
activity. On the contrary, it may be weeks, months, or even a few years 
before functional activity is manifested. 

The first sign of functional activity is a slight contraction of the muscles 
supplied by the lower of the three branches of the pes anserinus, namely, 
the muscles of the lower lip and the angle of the mouth. At a little later 
period the muscles of the upper lip and of the forehead show functional 
activity. 



THE SURGERY OF THE FACIAL NERVE 845 

A still later development is the contraction of the facial muscles simul- 
taneously with the act of deglutition. This gradually increases until the 
contraction on the paralyzed side is greater than on the unaffected side, 
and is very disagreeable to the patient. 

The simultaneous contraction of the facial and hypoglossal muscles 
annoys and confuses the patient. He soon learns, however, to dissociate 
the movements, and is able to swallow with a constantly decreasing 
degree of facial distortion, until finally the facial muscles remain quiet 
during the act of deglutition. 

The final and most desirable result is the voluntary contraction of the 
facial muscles independent of the act of swallowing. 

The time equired to obtain such a result varies greatly, depending 
upon the amount of muscle degeneration before the operation, the accu- 
rate apposition of the two nerves, and the general condition of the 
patient. 

The reaction of the muscles supplied by the facial nerve should be 
tested with the electric current, in long-standing cases, to determine 
whether they are still active. If contractions are not produced — that is, 
if complete atrophy of the muscles is present — it is useless to operate. 
The contraction of the masseter muscles should not be mistaken for the 
contraction of the facial muscles. One case of fourteen years' standing 
was successfully operated. 



CHAPTER L. 

DISEASES OF THE PERCEPTION APPARATUS. AUDITORY 
NERVE APPARATUS. 

HYPEREMIA OF THE LABYRINTH. 

Etiology. — The etiology is generally associated with either congestion 
of the middle ear or the contents of the cranial cavity. It is rarely 
primary in the labyrinth. It is usually found in acute suppurative 
otitis media following scarlet fever, diphtheria, and typhoid fever. It 
may also be caused by the other exanthematous fevers, pneumonia, 
encephalitis, mumps, puerperal fever, meningitis, and tumors at the 
base of the brain. Thrombi in the sinuses of the petrous portion of 
the temporal bone and the internal jugular vein, goitre, angioneurotic 
congestion of the cranial vessels, intracranial affections of the trigeminus, 
diseases of the medulla oblongata, and the internal use of quinine, 
salicylic acid, and amyl nitrite may also cause it (Politzer). 

Symptoms. — The symptoms are tinnitus, slight feeling of fulness in the 
head and ears, nausea, vomiting, and unsteady gait. The handle of the 
malleus may be injected, and, when present, denotes a general hyper- 
emia of the organ of hearing. The face and auricle may in rare cases be 
red. If there is a sense of dazzling whiteness before the eyes, the hyper- 
emia is probably of intracranial origin. 

Treatment. — If the hyperemia is secondary to middle-ear inflamma- 
tion, special attention should be addressed to that disease, and with the 
subsidence of the middle-ear disease the labyrinthine symptoms will dis- 
appear. The patient should be put in bed, given laxatives, and" have 
leeches applied to the nape of the neck and mastoid process. If there is 
active inflammation in the middle ear and mastoid process, the ice-bag or 
Leiter's coil should be applied to the mastoid region. 

If the disease arises from an intracranial lesion, the treatment, shoidd 
be addressed to that condition, the ice-bag applied to the vertex, saline 
cathartics given, and alcoholic beverages and tobacco prohibited. In 
general, the habits should be well regulated, constipation prevented, and 
the beneficial effects of fresh air and sunshine should be taken advantage 
of by the patient. 

ANEMIA OF THE LABYRINTH. 

Etiology. — The etiology is usually a co-existing general anemia. It 
may exist, however, as a local condition, due to the obstruction of the 
internal auditory artery from aneurysm of the basilar artery, neoplasms 



HEMORRHAGE INTO THE LABYRINTH 847 

of the dura or brain extending into the internal auditory canal, emboli of 
the internal auditory artery, and atheromatous constriction of the internal 
auditory artery. 

Symptoms. — In the angioneurotic and posthemorrhagic forms, the 
symptoms closely simulate those of seasickness; there is nausea, 
vomiting, severe tinnitus aurium, deafness, facial pallor, and dizziness. 
All these symptoms disappear with the return of the blood to the normal 
state. In the chronic form the tinnitus and deafness are the chief 
symptoms. 

Treatment. — If the labyrinthine anemia is angioneurotic in origin, 
the neurosis should receive appropriate attention; perhaps a long sea 
voyage, residence in the mountains or at the seashore, primitive camp 
life, etc., might be beneficial. If it had its origin in an excessive 
hemorrhage, transfusions of normal saline solution should be given, 
or spontaneous relief may come after a more or less prolonged period of 
waiting. If it occurs in one who is subject to repeated severe hemor- 
rhages, the duration of the ear symptoms is somewhat prolonged, and 
means to prevent the recurrances of the hemorrhages should be carefully 
considered in the treatment. In the angioneurotic type the internal 
administration of the bromide of soda and the application of the gal- 
vanic current to the sympathetic nerves of the neck are indicated. 



HEMORRHAGE INTO THE LABYRINTH. 

Small hemorrhages into the labyrinth may occur during the course 
of the exanthematous fevers, on account of the increased blood pressure 
and the rapid degenerative changes which sometimes characterize the 
progress of the diseases. The hemorrhages also occur in caisson workers 
and divers, and in prolonged suffocative seizures. Diabetes, nephritis, 
and sudden cessation of menstruation also cause it. Atheromatous 
degeneration of the walls of the arteries predispose to labyrinthine 
hemorrhage. 

More extensive hemorrhages into the labyrinth occui' in fractiu'es of 
the skull, involving the petrous portion of the temporal bone; from 
severe contusions of the skull; from extension of carious processes in 
the temporal bone, and from primary and tu])erculous meningitis 
(Politzer). 

Course and Termination, — 'J'he course and Icnninatiou of the 
hemorrhages into the hd)yrinth are obviously vai-i;il)Ie, according to their 
severity and origin. The blood clots j)ersist in the labyrinth for a variable 
time, after which they may be absorbed, become orgam'zed, or the epi- 
thelium, connective' tissue, nerve elements, etc., involved by the pressure 
may l)econie Mtrf)j)hi('d and degenerated, l^olitzer reports a case which 
ended in snppin-alioii. 



848 I'lIE EAR 



MENIERE'S DISEASE. 

I'his condition is characterized by sudden and complete loss of hearing, 
attended by tinnitus, nausea, vomiting, and vertigo, without a previous 
history of ear disease. It is supposed to be due to a hemorrhage into the 
labyrinth. The patient is usually robust, middle aged, and has never 
previously complained of deafness. At the onset of the attack he some- 
times falls unconscious to the ground. In a case seen by the author the 
attack came on at night. The patient upon attempting to rise in the 
morning had severe dizziness (indeed, could not walk), nausea, vomiting, 
tinnitus, and complete deafness. The history of the case showed that two 
years previously the left ear was similarly affected, the hearing remain- 
ing almost nil in that ear, the right being normal. It is now ten years 
since the last attack, and the hearing is but little improved. 

The hearing by bone conduction is lost if the affection is bilateral, and 
if it is unilateral the sound of the tuning-fork, when placed on the vertex, 
will be lateralized toward the sound side. 

The course of INIeniere's disease varies. The unconsciousness rapidly 
disappears, and the vomiting a little more slowly. The dizziness and 
staggering gait remain for several days. In my case the patient had a 
tendency to walk to the right, into the gutter or walls of buildings, for 
four or five weeks after the apoplectiform attack. He was dazed, and 
thought slowly for some weeks. His handwriting was not tested. Guye 
and Politzer report that for a time the handwriting is like that of a tremu- 
lous old man. The unsteady gait may persist for years. Relapses usually 
occur, although there are exceptions to the rule. 

Diagnosis. — The diagnosis of Meniere's disease can only be made with 
certainty when the patient is examined immediately after the seizure. 
If, then, the middle ear, drinnhead, and Eustachian tubes appear normal 
and the patient gives the clinical picture just described, and there is no 
paralysis of other cranial nerves, a diagnosis of Meniere's disease may 
be made. 

Prognosis. — The prognosis is unfavorable, little improvement being 
reported in the cases thus far recorded. 

Treatment. — The treatment is directed principally to the relief of 
the dizziness, nausea, and vomiting. The patient should be placed in 
bed with the head slightly raised, to avoid the necessity of changing 
his position in giving food and medicines. This precaution should be 
observed for a few clays while the symptoms are annoying. Cold com- 
presses to the head, mustard plasters to the nape of the neck and calves 
of the legs, and the administration of purgatives may hasten the disap- 
pearance of the annoying symptoms. The tinnitus is often relieved by 
the administration of quinine and the iodide of potash, or, what is prob- 
ably preferable, iodonucleoid, in which the iodine is united with nucleinic 
acid, thus rendering it readily digestible and easily and rapidly 
absorbed, without irritation of the stomach. If the quinine causes 
mental excitement and increased tinnitus, its use should be discontinued 



MENIERE'S SYMPTOM COMPLEX 849 

(Charcot). It should be given in two to five-grain doses three times 
daily for six or eight weeks. The iodide of potash (or iodonucleoid) may 
be given for three or four weeks. 

To promote absorption of the blood clot and exudate, pilocarpine, in 
2 per cent, solution, may be injected 4 to 10 drops daily; or it may be 
given internally for the same purpose. Its use should not be begun until 
about the third week, when the acute symptoms have subsided. 



MENIERE'S SYMPTOM COMPLEX. 

This condition, while similar in its manifestations in many respects to 
Meniere's disease, should not be confounded with it. jMeniere's symp- 
tom complex is characterized by dizziness, staggering gait, nausea, 
tinnitus, and more or less deafness, with a distinct history of previous 
deafness and ear disease. The deafness is not sudden and complete, nor 
are the profound disturbances found in true Meniere's disease present. 
The author once saw a case in consultation, in which nearly all the signs 
of JMeniere's disease were present, the exceptions being: (a) There was 
a history of previous deafness and ear disease; ib) the deafness was 
not sudden or profound; (c) inflation of the middle ear through the 
Eustachian catheter gave immediate and complete relief of all the 
symptoms. The case was one of Eustachian catarrh, complicating 
a similar process in the epipharynx. The air in the middle ear became 
gradually rarefied by the absorption of the oxygen from it by the blood, 
the drumhead was retracted, and pushed the foot plate of the stapes 
inward, thus compressing the intralabyrinthine fluids, and giving rise to 
the foregoing phenomena. The same phenomena may be due to chronic 
catarrhal adhesive processes. According to Politzer, a great majority of 
the cases are due to a temporary congestion of, or exudation into, the 
labyrinth, arising in the course of middle-ear affections, which bring- 
about an irritation of the vestibular and ampullar nerves. 

Dr. Geo. E. Shambaugh recently advanced the idea that the tinnitus 
attending this affection is due to a disturbance of the relation of the 
membrana tectoria to the hair cells of the organ of Corti. He holds that 
the membrana tectoria is the resonator of the perception apparatus, 
whereas according to Helmholtz the basilar membrana is the resonator. 
(See Physiology of the Labyrinth.) 

The use of the tuning-fork enables the observer to dilferenliiitt' between 
those cases of middle-ear origin and those of lalnrindiine origin. Jf 
with marked diminution of liearing there is ])ositive Uinne, with hearing 
for low tones jjreserved, the lesion is in the labyrinth; if, on the contiaiy, 
there is a negative Uinne, with loss of hearing for low tones, th(> h\sion 
is in the conduction ])oi-tion of the temporal ))onc, /'. r., in the nn'ddle ear 
or Eustachian tiil)c. if ihc .|l>r;i,M' is nnilatcial, the vibrating tnning- 
fork placed upon the \cit<'\ will, if Ihc lesion is in Ihc middle eai- or 
Eustachian tube, lateralize lowai-d Ihc idlVdcd side; whercns. if il is in 
the labyrinth it will latei'alizc towai'd llic norin;d or niiall'ected side. 
54 



850 THE EAR 

Some cases reported by Pritchard and I>ake had an epileptiform 
type, with a tendency to fall toward the affected side. The room seemed 
to whirl, the face became pale, the eyes dull, skin covered with cold 
perspiration, and the pulse was small and often retarded. 

The course of the symptoms is extremely variable, lasting from a few 
moments to several days or weeks. 

Treatment. — In those cases due to hyperemia of and exudation into 
the labyrinth the same treatment recommended under hyperemia of the 
labyrinth is of value here. If the lesion is in the Eustachian tube or 
middle ear the remedies suited to the condition present should be used. 
Quinine is perhaps more valuable for the relief of the tinnitus than it is 
in Meniere's disease. Pneumomassage, especially rarefaction (suction) 

Fig. 471 




Siegle's otoscope. 

of the air in the external meatus, in either the middle ear or labyrinthine 
type, is highly beneficial in many cases. Its rationale is in the outward 
movement of the drumhead, thus relieving the pressure upon the foot 
plate of the stapes, and in the labyrinthine type the lessened pressure in 
the middle ear relieves the labyrinthine congestion. Rarefaction can be 
practised by means of a rubber tube with a meatal tip, the patient supply- 
ing the suction power with his mouth at the other end of the tube, or it 
may be done with an electromotor engine and pump, to which is attached 
Siegle's otoscope (Fig. 471). The Victor electromotor engine and pump 
is so constructed as to give either rarefaction, condensation, alternate 
condensation and rarefaction, intermittent rarefaction, or constant rare- 
faction, hence it is admirably adapted to the needs of the otologist. 



INFLAMMATION OF THE LABYRINTH; OTITIS INTERNA; 
LABYRINTHITIS. 

Acute Primary Inflammation of the Labyrinth (Voltilini). — This 
type of labyrinthitis is usually mistaken for an acute meningitis. There 
are differences, however, which will enable one to make a differential 
diagnosis. Voltilini gives the following characteristics: (o) It occurs in 
children who were previously healthy, (6) with a sudden rise of tempera- 
ture,^ (c) the face very red, {d) vomiting, followed by (e) unconscious- 



INFLAMMATION OF THE LABYRINTH 851 

ness, delirium, and convulsions; (/) after a few days all these symptoms 
disappear, {g) leaving the patient totally deaf and with a staggering gait, 
which persists for some time. 

Acute Labyrinthitis Secondary to Meningitis.— This is followed by 
total deafness and sometimes by a staggering gait. The acute symptoms 
usually continue for several weeks, whereas in the acute primary inflam- 
mation of the labyrinth of Voltilini the acute symptoms disappear in 
a few days. Politzer calls attention to the fact that an intracranial 
affection may lead to a total paralysis of the acoustic nerve, generally 
involving some of the other intracranial nerves as well; but that it does 
not necessarily do so, as pointed out by Gottstein, in the abortive type of 
epidemic cerebrospinal meningitis. Hovell also questions Voltilini's 
conclusions. It seems to the author that, while Voltilini may have erred 
in reaching such a broad conclusion, namely, that those cases presenting 
the meningeal symptoms for only a few days, followed by deafness and 
staggering gait, were all acute primary inflammations of the labyrinth. 
He should, nevertheless, be given the credit for calling attention to the 
fact that some of the cases presenting this clinical history are, in all prob- 
ability, limited to the labyrinth, although some of them are probably 
abortive t}'pes of meningitis. 

Chronic Primary Inflammation of the Labyrinth. — To Politzer be- 
longs the honor of first reporting the anatomical and microscopic appear- 
ances of a case of chronic primary inflammation of the labyrinth. In 
his case the following facts are of interest: (a) A boy was affected by 
fever of two weeks' duration; (6) aural discharge from both ears until 
the sixth or seventh year of age; (c) at no time was there a staggering 
gait; {d) he died at the age of thirteen of acute peritonitis. The post- 
mortem findings: (e) No middle-ear involvement, except ankylosis of 
the foot plate of the stapes in both ears; (/) the cavities of the cochlea, 
vestibule, and semicircular canals were filled with newly formed bone 
tissue; {g) the acoustic (auditory) nerve fibers were unchanged up to the 
point of entrance into the new bone tissue. 

The types of primary inflammation of the labyrinth are, according to 
Gruber, plastic and exudative. The first is a simple hyperplasia, while 
the latter may be serous, serohemorrhagic, or purulent. 

The causes of secondary inflammation of the labyrinth are injuries, 
and in the purulent type the labyrinth is invaded by germs. The 
other causes are generally obscure, and are variously designated as 
resulting from a "cold," metastasis, etc. It is undoubtedly sometimes 
due to syphilis, tuberculosis, and the exanthemata, as well as to menin- 
gitis. A frequent cause of the secondary inflammation is caries and 
necrosis extending from the middle ear, especially in connection with a 
tuberculous process in these parts. 

Pathology. — The pathological findings following inflammation of 
the lal)yrintli are: (a) Newly formed connective tissue; (6) calcareous 
degeneration, {c) hyperostosis of the osseous walls of the lal)yrinth; {d) 
bony hs-perplasia in tlie spaces of the labyrinth; (e) angio-conncctive- 
tissue growths in the cavity of the Inbyrinth; (/) tliickening of the semi- 



852 THE EAR 

circular canals, utricle, ampullae, and saccule; {g) cholesterin, pigmen- 
tation, and calcium salts in the membranous labyrinth; {h) epithelial 
thickening on the inner wall of the saccule, utricle, and scalje of the 
cochlea (Politzer); (/) fatty degeneration and atrophy of the organ of 
Corti; (y) necrosis in the tuberculous and syphilitic cases, as well as in 
those cases having their origin in {k) necrosis of the middle ear. 

Symptoms. — In Voltilini's type of acute primary inflammation of 
the labyrinth the disease is ushered in (in children) by a sudden rise in 
temperature, the face is quite flushed and red, with vomiting, followed by 
unconsciousness, delirium, and convulsions. \Yithin a few days these 
symptoms entirely disappear, leaving the patient quite deaf and with a 
staggering gait, which may persist for a long time. In the type second- 
ary to meningitis the meningeal symptoms usually persist for several 
weeks, and leave the patient deaf and sometimes with a staggering gait. 
The chief diagnostic point is in the shorter duration of the acute menin- 
geal symptoms in the primary inflammation of the labyrinth of Voltilini. 

In the secondary form the symptoms are more obscure, being compli- 
cated by those of the primary affection. The functional tests of hear- 
ing must be chiefly depended upon for the diagnosis. The signs present 
are those of labyrinthine disease in general, namely, (a) diminished bone 
conduction on the affected side, and (h) loss of hearing for the high tones 
of the Galton whistle. In exceptional cases the hearing for high tones 
is not affected, even in pronounced destructive changes. In the use 
of the tuning-fork and whistle, the Weber test shows lateralization 
of hearing toward the unaffected side, while the Rinne is positive. 
The tests should be applied on several occasions before pronouncing a 
final opinion. 

The subjective symptoms are: more or less deafness (often being com- 
plete and sudden), tinnitus, a feeling of fulness or of pressure in the ears, 
giddiness, vomiting, and a staggering gait. 

Inflammation of the laljyrinth following cerebrospinal meningitis 
may occur at the beginning of the disease or at its close. The patient 
being unconscious and in bed, the deafness and staggering gait are 
often not noticed until the mind is clear and the patient attempts to walk. 
In the type secondaiy to scarlet fever and diphtheria the labyrinthine 
inflammation usually follows an otorrhea. 

Prognosis. — The prognosis is usually unfavorable. ]Moos has 
wisely said that the percentage of cures and improvements has been 
much larger in the hands of the general practitioner than in the hands of 
specialists; he accounts for this by the fact that the general practitioner 
sees the case early, before the changes are so marked. Hence, we may 
conclude that the prognosis is more favorable if the case is seen early. 
The prognosis is also more favorable when there is unilateral involve- 
ment. If, during convalescence, the patient hears subjective sounds and 
has perception for musical tones, the prognosis is more favorable (INIoos). 
Politzer reports that in his experience there may be a fair return of hear- 
ing, with subsequent loss of it. If a child is aft'ected before he learns 
to speak, or soon afterward, he will become a deaf-mute. In the sup- 



PANOTITIS 853 

purative type, pachymeningitis, in the posterior cranial fossa may occur, 
the infection passing through the sheath of the auditory nerve. 

Treatment. — The treatment, on the whole, is not likely to result in 
the restoration of the faculty of hearing. There are other considerations, 
however, that render it quite important that appropriate treatment be 
given. For example, (a) the extension and severity of the pathological 
process may be favorably modified; (6) the case may be of recent syph- 
ilitic origin, and yield to treatment; (c) the intensity of the fever may be 
modified, and thus save the life of the patient; and (d) the child may 
be prevented from becoming a deaf-mute by appropriate training given 
at the proper time. 

If the disease is secondary to an inflammatory affection of the middle 
ear or epipharynx, this should be carefully attended to. The func- 
tional activity of the bowels and kidneys should be watched and regu- 
lated. Calomel, followed by saline cathartics, may prove of value. If 
the temperature is high, the pvdse rapid and hard, and the skin dry, 
antipyrine in v-x gr. doses, hourly, for four to six hours, followed by 
gr. X of Dover's powder and a hot lemonade, will lower the temperature 
and pulse and moisten the skin, and thus greatly relieve the patient of 
discomfort and delirium. Leeches may also be applied over the mas- 
toid process for the same purpose. In the meningeal types, and in the 
acute primary inflammation of the labyrinth, ice-bags to the head are 
of great aid in relieving the fever and delirium. Iodide of potassium, or 
iodonucleoid, and mercury may be given in syphilitic cases, especially 
if they are recent. They are of no value in the congenital types. 
Blisters and counterirritants over the mastoid and in front of the ear 
may also be tried. 

If the child has not yet learned to speak, he will surely be a deaf-mute, 
and should be placed in a school where he will receive careful training. 
If he has learned to speak, and is under seven years of age, he will 
almost certainly lose the speech already acquired unless vigorous and 
intelligent attempts are made to perpetuate it. If he is more than seven 
years old, he is much more apt to retain his speech and use it in conver- 
sation. It is important, therefore, that the physician should impress 
upon the family the need of special training, to prevent the child becom- 
ing a deaf-mute. He may be deaf, but he need not necessarily also 
become a mute. (See Deaf -mutism.) 

PANOTITIS. 

This affection is characterized })y an inflammation involving, simul- 
taneously or in rapid succession, the middle ear and labyrintli. It usu- 
ally has its origin in scartalinodiphtlicria, idfecling both ears, which in a 
siiort time causes complete deafness. The ])rognosis is very unfavor- 
able, although some German writers have rej)()rt(>d good results under 
treatment. Pilocarpine injections in small doses for sev(M-al months 

hiivc ;i])parently given ^imkI i-csiiI|s in ;i few ciisc^. The indidc of 
j)()(;issiiiin, iodide of ;iiiiiii()iii;i di' ioddiiuclcoid, ;iiid iiicrcnry ni'c 
;dso rer()inin<'ndcd. 



854 THE EAR 



LEUKEMIC DEAFNESS. 

Leukemic deafness is characterized by either sudden and complete 
deafness and Meniere's symptoms, or by moderate deafness, whicli 
speedily grows worse until, within a few weeks or months, there is total 
deafness. In acute leukemia the deafness, etc., occur in the early 
stage of the disease; whereas in chronic leukemia the deafness and 
other ear symptoms usually appear in the later stages. The patho- 
logical changes consist of accumulations of lymphocytes, and hemorrhages 
into the labyrinth, followed by a reactionary inflammation of the endos- 
teum and membranous labyrinth, which finally results in connective- 
tissue obliteration and partial ossification of the labyrinth (Politzer). 
The prognosis is obviously unfavorable. 



OTITIS INTERNA PAROTITICA. 

Mumps being an infectious disease, and the site of infection being 
anatomically in close proximity to the labyrinth, the infection may be 
carried to it by metastasis, or it may be carried through the Gasserian 
fissure. The symptoms are slight vertigo, with or without vomiting, 
and sudden deafness on one or both sides. Iodides internally sometimes 
act favorably upon the course of the disease. 



SYPHILIS OP THE INTERNAL EAR; SYPHILITIC OTITIS INTERNA. 

The syphilitic diseases of the labyrinth usually appear at the end of the 
secondary or at the beginning of the tertiary stage. Politzer, however, 
reports a case in which there was lal)yrinthine involvement seven days 
after the initial lesion. It may involve the labyrinth in common with 
the middle ear, or as one of the signs of a general infection, or it may be 
limited to the internal ear. 

Pathology. — The pathology is but little known, as only a few cases 
have been carefully studied. From the examinations made it appears 
that there is either thickening of the periosteum of the vestibule (Toyn- 
bee, Moos), the foot plate of the stapes displaced and fixed, small-cell 
infiltrations and h}^erplasia of the connective tissue between the mem- 
branous and bony labyrinth; also infiltration of Corti's organ, the am- 
pullae, and membranous semicircular canals (Moos). The canals and 
spaces of the labyrinth have also been found filled with new bony tissue. 
The acoustic nerve may or may not be affected. Adhesive bands, 
hornification, atrophy and destruction of the ganglionic cfells, and 
syphilitic endarteritis (Baratoux and Virchner) have been reported. 

Symptoms. — The symptoms are those of labyrinthine involvement 
in general, namely, loss of hearing by bone conduction, and for high 
tones. If the affection is unilateral (rare), the Weber experiment will 



SYPHILIS OF THE INTERNAL EAR 855 

show lateralization of hearing to the normal side, and Rinne will be 
decidedly plus upon the affected side. The symptoms may appear sud- 
denly, with tinnitus, deafness, dizziness, and staggering gait. The deaf- 
ness may become complete and permanent, the tinnitus increasing at the 
same time. The staggering gait and dizziness may disappear after a few 
weeks or months. Diplacusis and pain in the ear may be present, the 
pain being due to a periosteal growth in the labyrinth.^ 

Objectively, the signs of syphilis of the internal ear may be wanting. 
It is only when the middle ear, or Eustachian tube, and labyrinth are 
simultaneously involved that objective signs are found. There may 
then be the usual appearance of a catarrhal otitis media, or the char- 
acteristic swelling of the mucosa of the Eustachian tube. Syphilitic 
ozena of the nose and epipharynx may also be present. 

Course. — In most cases the deafness develops gradually for some 
weeks or months, remains stationary, and then, after a variable interval, 
suddenly becomes much worse. More rarely the deafness comes on sud- 
denly. Slight exciting causes may cause a rapid increase in the deaf- 
ness. Concussions on the head, blows, etc., have been known to do it. 
In rare cases improvement and recovery take place, and hearing by bone 
conduction gradually returns. 

Diagnosis. — The differential diagnosis between syphilis, hyperostosis 
of the bony capsule of the labyrinth, and other forms of labyrinthine 
disease is not always easy. If there are evidences of the secondary or 
tertiary manifestations of syphilis, it is easy to make a diagnosis. Un- 
fortunately, in many cases no such obvious signs are present, and the 
diagnosis is, therefore, much obscured. Politzer observes that "those 
forms of severe or total deafness which usually develop in both ears dur- 
ing childhood must be regarded as syphilitic affections of the labyrinth. 
Such cases were formerly supposed to be due to scrofula." The diag- 
nosis of hereditary syphilis is aided by the presence of middle-ear catarrh, 
purulent otitis media, adhesive processes of the middle ear, and chronic 
interstitial keratitis (opacity of the cornea). 

Prognosis. — Recent cases offer a favorable prognosis, while older 
ones are quite unfavorable. The degree of deafness is not a safe guide 
in giving a prognosis, as totally deaf cases have been known to recover, 
while others, with mild deafness, have remained unimproved. General 
debilitating diseases render the prognosis more grave. The hereditary 
type, with opacity of the cornea, is unfavorable. 

Treatment. — Mercurial injections, with the internal administration 
of iodonucleoid or iodide of potassium, are indicated. Pilocarpine 
injections, 4 to 12 drops daily, beginning with 4 drops and increasing 
to 12 drops, sometimes influences the case favorably (Politzer, Bacon, 
Gradenigo). The injection of solutions of the iodide of potassium into 
the middle ear through the Eustachian catheter, as reconunended by 
Politzer, is not to be generally recommended. The technique of such 
a procedure opens it to extreme liability of carrying infection into the 

' Moss and Steinbrugge, Z. f. O., vol. xiv. 



856 THE EAR 

middle ear. Under strict antiseptic precautions and a knowledge of 
the extremely small size of the tympanic cavity, and the technique of the 
whole procedure, the danger of infection disappears; and it is possible, 
though to my mind not probable, that the injection of a solution of the 
iodide of potassium will affect the course of the disease favorably. The 
injections of iodoform, iodine vasogen, mercurial ointments, etc., are 
more rational methods of treatment. It should not be forgotten, 
however, that the disease is essentially a systemic one. 



SUPPURATION OF THE LABYRINTH. 

Labyrinthine suppuration probably occurs in about 1 per cent, of the 
cases of middle-ear suppuration. It has rarely been diagnosticated, be- 
cause the subjective symptoms are not absolutely characteristic, and be- 
cause the condition has not been generally understood by otologists until 
within the last few years. Suppurative leptomeningitis is a serious 
sequela or complication of labyrinthine suppuration, and the symptoms 
in some respects are quite similar, hence it is quite probable that many 
of the cases diagnosticated as leptomeningitis have been labyrinthine 
suppuration, at least in their initial manifestation. 

Etiology. — Suppurative otitis media, with involvement of the mas- 
toid antrum, is the most common cause of disease, though scarlet fever, 
measles, influenza, and tuberculosis may also cause it. In the 45 cases 
reported by Bezold about 50 per cent, were in children. The vulnerable 
points through which the infection may take place are the round and 
oval windows and the pneumatic spaces around the labyrinth. The 
retention of the secretions and the accumulation of cholesteatomatous 
material in the attic, aditus ad antrum, and the antrum may cause 
pressure necrosis, and thus expose the horizontal and perpendicular 
semicircular canals to infection. The facial nerve may also be exposed 
by the same process, as it lies in close proximity to the horizontal semi- 
circular canal in the floor of the antrum. The pneumatic spaces 
sometimes extend behind the lal:)yrinth, hence the labyrinth may be 
invaded from this direction. The cells beneath the floor of the middle 
ear also extend beneath the labyrinth, and should necrosis extend in this 
direction, labyrinthine involvement may follow. The promontory is 
rarely the seat of necrosis except when there is extensive destruction of 
bony tissue in which the promontory is involved. When such a condi- 
tion is present, granulations usually spring from the area, and the use of a 
probe-point shows roughened bone or a perforation. 

The value of ocular myoseismia in the differential diagnosis of cerebellar 
abscess and suppuration of the labyrinth is pointed out by Neumann. 
In suppuration of the labyrinth the myoseismia (Neumann calls it 
nystagmus) becomes less and less marked, and finally disappears as 
the suppuration extends; while in cerebellar abscess the myoseismia 
increases as the disease progresses. In suppuration of the labyrinth it 
occurs in the begimiing, when the eye is turned toward the diseased side; 



SUPPURATION OF THE LABYRINTH 857 

whereas the strabismus may disappear and the myoseismia still be 
present when the eye is turned to the well side. In cerebellar abscess 
the conditions are reversed, and the myoseismia is first observ^ed when 
the eye is turned to the normal side, and is later turned to the diseased 
side. When this form of myoseismia is observed a positive diagnosis of 
cerebellar abscess can be made. Another point in the diagnosis is that, 
after the labyrinth has been opened by operation, the myoseismia due 
to the labyrinth trouble rapidly subsides, while the myoseismia due to 
the cerebellar abscess remains the same. 

The etiology of the extension of the labyrinthine suppuration is 
explained by the avenues of least resistance which extend in that direc- 
tion, viz., the internal auditory meatus (sheath of the auditory nerve) 
and the cochlear duct. The infection may also gain entrance to the 
cranial cavity through a dehiscence or a necrosis of the perpendicular 
semicircular canal. If the infection extends through the cochlear duct 
it enters the subarachnoid spaces and is necessarily a very dangerous 
condition. 

The intracranial complications most apt to attend labyrinthine suppu- 
ration are suppurative meningitis and extradural abscess, though abscess 
of the cerebrum and cerebellum and infective lateral sinus thrombosis 
occasionally occur. 

Symptoms. — When rightly understood the symptoms of labyrinthine 
suppuration are usually very well defined. There are certain charac- 
teristic symptoms which should at least lead to a tentative diagnosis. 
The objective symptoms are not usually obvious, though in some cases 
the presence of granulations, roughened bone, and the oozing of pus 
from the inner wall of the middle-ear cavity may be seen. When pres- 
ent they may appear at one of three places, namely (a) the round 
window, (b) the oval window, or (c) the promontory. Facial paralysis 
may also be present, as the facial nerve is often involved in the necrotic 
process attending the suppurative labyrinthitis. 

Diagnosis. — The diagnosis may be made without the foregoing ob- 
jective signs in many cases from the presence of pronounced deafness, 
tinnitus, vertigo, and headache. The deafness is more pronounced 
than is usual in middle-ear disease. The hearing for the tuning-forks 
and whistles is usually greatly diminished at both the lower and upper 
limits, more particularly the upper, or it may be entirely lost. Bone 
conduction is greatly diminished or entirely lost. The vertigo may be 
accompanied by nausea and vomiting. Horizontal nystagmus (ocular 
myoseismia) has been observed In' Neumann. 

The deafness may be partial or complete, depending iij^on wlu>tlier tlie 
labyrinth is completely or partially destroyed. Goldstein, of St. Louis, 
and others have reported cases in w'mcIi there was exfoliation of the 
cochlea, in which there apparently still remained con8i(leral)le power 
of hearing. Bezold, Ilovell, Ilartmann, Corradi, rolitzer, the author, 
and others have shown that ev(>n with the most coniplele precautions it 
is impossible to exclude hearing with the nnallVctc( 



riic meatus 



of the sound ear mav be ever so tightly stopped, and still admit some 



858 THE EAR 

sound waves which may be heard. Then, too, sound waves may reach 
the normal ear by bone conduction. Pynchon has suggested the use of a 
long speaking-trumpet, to remove the source of sound as far as pos- 
sible from the normal ear. Even with all these, and other precaution- 
ary measures, the sound waves seem to leak through the barriers to the 
other ear. It is not probable, or even possible, that the sound waves are 
perceived by the stump of the auditory nerve after its endings in the 
labyrinth have been destroyed. 

Paresis or paralysis of the facial nerve is present in all cases in which 
the cochlea is exfoliated. This is accounted for by the intimate ana- 
tomical relationship of the parts, the nerve being either pressed upon or 
destroyed by the necrotic process and the exfoliation of the cochlea. 
The nerve is affected in about 55 per cent, of the cases. Hovell divides 
the course of the nerve into four parts, namely: (a) Within the internal 
meatus, where it is liable to be affected in the exfoliation of the entire 
labyrinth, and give rise to permanent impairment — complete or partial 
— of the function of the facial and auditory nerves. (6) The second divi- 
sion extends from the beginning of the aqueductus Fallopii to the genicu- 
late ganglion, and is less liable to injury, (c) The third division passes in 
close proximity to the vestibular walls, and, in case of vestibular necrosis, 
the nerve is in great danger, (d) The fourth division, or lower portion, 
passes downward through the mastoid process, and is in danger when 
there is extensive mastoid necrosis, but is in little danger from laby- 
rinthine necrosis. Exuberant granulations may exert pressure upon the 
sequestrum, and thus give rise to facial paralysis. 

Restoration of the Facial Nerve. — Bezold and others have reported 
cases in which there was undoubted loss of the substance of a portion of 
the facial nerve in the course of necrosis of the labyrinth, in which there 
was subsequent regeneration and restoration of its function. The 
chorda tympani is more often destroyed than the facial nerve, and is 
often restored. It seems, therefore, that there is a strong regenerative 
power in the facial nerve when destroyed by necrosis, and when it is 
severed in an operation. One should not infer from this statement, 
however, that he should regard the facial nerve with indifference during 
a mastoid operation, as many do not thus regenerate and resume their 
function. The surgical anastomosis of the facial with the hypoglossal 
nerve (see pp. 841 and 847) offers a means for re-establishing the move- 
ments of the muscles supplied by it, and the dread of facial paralysis is 
somewhat lessened, though by no means removed. 

The sequestra vary in size and anatomical composition. The whole 
petrous portion may come away, the cochlea alone or with contiguous 
bone, the labyrinth, or the semicircular canals (one or more) may be 
exfoliated. 

Contrary to the opinion expressed by Blake and Reik, in their clas- 
sical treatise on the Surgical PatJiology and Treatment of the Diseases 
of the Ear, I believe labyrinthine suppuration may usually be diag- 
nosticated before operative interference is instituted. 

The following comparative table shows the symptoms present in 



SUPPURATION OF THE LABYRINTH 



859 



middle-ear suppuration, and in middle-ear suppuration combined with 
labyrinthine suppuration : 



Middle-ear Suppuration. 

1 . Moderate deafness. 

2. Range of hearing, lower tone limit 

lost. 

3. Bone conduction incre 



4. Aural vertigo absent. 

5. Tinnitus not pronounced. 

6. Facial paralysis is occasionally 

present. 

7. No granulations, and oozing of pus 

from the inner tympanic wall. 

8. Pus on inner wall when wiped away 

does not soon return. 

9. Probing shows no carious bone on 

inner wall. 

10. Meningeal and intracranial symp- 

toms may be present. 

11. Spinal puncture shows normal 

spinal fluid. 



Middle-ear Suppuration Combined with 
Labyrinthine Suppuration. 

1. Pronounced deafness. 

2. Low and high tone limits lost, or 

the deafness is complete 

3. Bone conduction diminished or 

entirely abolished. 

4. Aural vertigo present. 

.5. Tinnitus pronounced, especialljr 
early in the disease. 

6. Facial paralysis is frequently 

present. 

7. Granulations and pus oozing from 

the inner tympanic wall. 

8. Pus on inner wall when wiped away 

soon returns. 

9. Probing occasionally shows carious 

bone on inner wall. 

10. Intracranial symptoms ma}^ be 

present. 

11. Spinal puncture shows cells and 

bacteria if the invasion of the 
cranium is through the cochlear 
duct. 



Prognosis. — The prognosis is always grave, 20 per cent, of the 47 
cases collected by Bezold ending fatally, though spontaneous recoveiy 
(as to life) may occur. The hearing is usually greatly impaired, whether 
the recovery is spontaneous or through surgical interference. The 
facial paralysis may or may not be present, or, if present, may or may not 
be permanent. Conservative operative treatment does not add to the 
mortality rate, though it may increase the degree of permanent deafness. 

Treatment. — The treatment of necrosis and suppuration of the 
labyrinth is obviously surgical, and the following indications should be 
met, viz. : (a) The morbid material should be removed; (h) free drainage 
should be established and maintained; and (c) asepsis (surgical clean- 
hness) of the parts should ])e maintained until regeneration (liealing) is 
comj)lete. 

(a) The removal of the morbid material should be effected through the 
external meatus or the mastoid process. If the meatus is crowded with 
granuhitions, they should be removed witli Wilde's snare, the forceps, 
curettes, or caustic applications of chromic acid. The granulations may 
1)6 still furtlier controlled by tlic instillation of alcohol. It may then be 
possible to remove the sequestrum through the meatus without further 
operative interference. In .some cases it will l)e necessary to remove the 
j)osterior wall of the meatus, while in othei's the mastoid process will 
have to be opened. Where the sequestrum is large, the radical mastoid 



860 THE EAR 

operation will have to be performed. Having removed the sequestrum 
in one of tliese ways, tlie other morbid material, as small particles of 
bone, granulations, cholesteatomatous material, pus, etc., should be 
sedulously looked for and removed. 

{h) The maintoiance of free drainage is accomplished by removing the 
morbid material — sequestra and granulations — thereby enlarging the 
drainage channel, and by the use of gauze dressings in the diseased cavi- 
ties. The gauze carries the secretions outward to the external gauze 
pads, and thus free drainage is established. 

(c) The mainienance of asepsis, the third indication, is met by the 
establishment of the free drainage, whereby the infective material is con- 
stantly discharged , and after a time, there being no more infective material 
within the wound, the gauze dressing effectually prevents the entrance 
of infective material. This state of affairs should be maintained until 
regeneration or epidermization is complete. 

It may be necessary in those cases where the posterior wall of the 
meatus is removed, and where a radical mastoid operation is performed, 
to resort to a skin-grafting operation, as described in connection with the 
mastoid operation. (See Grafting Operation, pp. 810 to 815.) In all 
obstinate cases the outer wall of the labyrinth should be removed, to 
establish free drainage. (See Surgery of the Temporal Bone, Bourguet's 
Operation.) 



INJURIES TO THE LABYRINTH; CONCUSSION OF THE LABYRINTH. 

Etiology. — The injury may be due to direct or to indirect violence, 
more commonly the latter. The violence may be transmitted through 
the bones of the head to the internal ear, or through the air and ossicles 
in the middle-ear cavity, where there is a sudden condensation of the 
atmosphere by a great explosion, or the blow of the hand over the ear. 
The bony capsule may be injured while the membranous capsule is 
unharmed, and ince versa. When a fissure of the skull passes through 
the labyrinth, it usually, also, extends to the middle ear and external 
auditory meatus, although this is not always the case. Great violence 
may produce pronounced aural disturbances without fracture of the bone. 
In those cases it is probable that there is excitation of the terminal nerve 
filaments of the labyrinth, small hemorrhages, etc. 

Injuries to the labyrinth from powerful compression of the atmosphere 
by explosions, boxing of the ears, etc., may or may not cause rupture of 
the flrumhead. Should the drumhead rupture, however, the labyrinth 
is prol)ably saved from some of the force of the concussion, as the air in 
the middle ear escapes through the ruptured drumhead, thus relieving 
the tension which would otherwise expend itself upon the foot plate 
of the stapes in the oval window of the labyrinth. 

Detonations from heavy ordinances, or loud reports of guns in shooting 
galleries, produce a great deal of harm to the terminal nerve filaments 
of the labyrinth by irritation, and result in more or less deafness and 
tinnitus (Sexton). 



OCCUPATION DEAFNESS 861 

Symptoms. — The symptoms vary with the severity of the concussion 
and the location and character of the lesion. If the concussion is power- 
ful the subject may drop to the ground as though he were shot, and 
remain in an unconscious condition for several hours, after which con- 
conciousness returns, and he finds himself to be entirely deaf. Or if the 
concussion is light, he will stagger, but not fall, and be stupid or dazed 
for a short time, with more or less tinnitus and deafness. There may 
also be nausea and vomiting, with more or less giddiness. If the blow 
or concussion causes fracture through the cochlea, the deafness will be 
pronounced; whereas if it passes through the semicircular canals, the 
staggering gait will be the prominent symptom. 

The hearing for high tones is lost or modified. Diplacusis and 
hyperesthesia acoustica are sometimes present. The sensibility of the 
skin of the auricle and meatus may be diminished. 

According to Politzer, "a medicolegal decision as to the existence of 
concussion of the labyrinth can be given only in those cases in which 
there is a fissure of the temporal bone extending to the external meatus, 
and in which an injury of the labyrinth may be inferred, either from 
the discharge of cerebrospinal fluid or from complete deafness and the 
absence of perception through the cranial bones." In the cases due to 
compression of air in the external meatus he says no opinion can be given. 

It may be of medicolegal importance to establish the degree of im- 
pairment of hearing, as the patient may seek redress in the courts. If 
he does so he will sometimes be tempted to magnify his auditory dis- 
ability. By the use of a series of tuning-forks, whistles, and other func- 
tional tests of hearing a correct diagnosis may be made. It will also be 
necessary to establish as nearly as possible the condition of his hearing 
apparatus before the injury. Lateralization of the sound in Weber's 
experiment to the injured ear signifies that the labyrinth is unaffected, 
whereas, lateralization toward the sound ear is strongly suggestive of 
labyrinthine involvement in the injured ear. The loss of high tones 
in the affected ear also points to labyrinthine disease or injury. Of 
course, it is necessary to prove or disapprove the presence of labyrinthine 
disease before the date of the injury. This is not often easy to do. The 
Rinne test is of little value when there is complete deafness, but may 
prove of some value when there is only partial deafness. 

Treatment. — Rest in bed constitutes the whole of the treatment in 
most cases, whether there is simple concussion or fracture through the 
labyrinth. Pain in the ear may be controlled with leeches applied to the 
mastoid region. Tinnitus of an aggravating character may l)e n^lieved 
by the administration of the bromide of soda. After the acute symi)t()ms 
have subsided iodonucleoid or the io(Hde of polassiiini should be 
administered to hasten the absoi-ption of the inllaiiuualory cxudale. 

OCCUPATION DEAFNESS. 

It has long l^een recognized that among those who for a long time 
have been engaged in certain occupations, especially where continuous 



862 THE EAR 

or frequently recurring sounds are heard, there is apt to ])e more or less 
deafness. The terminal nerve filaments of the labyrinth, being con- 
tinuously subjected to irritation, undergo a degenerative change often 
amounting to complete atrophy, and consequent paralysis of the acoustic 
nerve. Occupation deafness has been obsened among blacksmiths, 
locksmiths, telephone operators, boilermakers, certain machine-shop 
workers, weavers, and railway employes. Among this class of workers 
it is probable that the continuous noise to which their ears are subjected 
causes an irritation of the acoustic nervous apparatus of the labyrinth, 
and to the circulatory apparatus as well, which after a long time causes 
a disturbance of the nutrition of the parts, and finally leads to degenera- 
tion, atrophy, and paralysis. Both ears are usually affected. 

There are other conditions peculiar to certain occupations, which 
cause dulness of hearing, as exposure to damp, cold atmosphere, dust, 
and superheated air. Stokers and engineers are particularly exposed 
to atmospheric changes, heat, cold, dust, and noxious vapors. They are, 
therefore, subject to nasal and epipharyngeal catarrh, and its extension 
to the Eustachian tube and middle ear. INIany, after from five to ten 
years' service on the road, have well-marked didness of hearing. Numer- 
ous observers have written on the subject, and their conclusions are as 
follows: (a) The deafness and tinnitus may be due to the constant 
vibratory movement of the locomotive, resulting in irritation to the 
terminal nerve filaments of the labyrinth; (6) constant straining of the 
ears to hear above the noise and roar of the train, is thought by some to 
cause the deafness; (c) cold draughts of air and the heat from the furnace 
cause epipharyngeal and aural catarrh; and {d) the inhalation of the 
noxious gases and vapors cause irritation and catarrhal inflammation 
of the nose, pharynx, and middle ear. 

The chief symptom of the catarrhal cases of occupation deafness are 
more less dulness of hearing, tinnitus, and in some cases giddiness. 
Rinne may be positive or negative according to the degree of deafness 
present. Hearing by bone conduction is increased. If the labyrinth is 
also involved the tests are somewhat confused, especially as to the rela- 
tive length of air and Ijone conduction, both being diminished. If there 
is also loss of hearing for high tones, the labyrinth may be safely said to be 
affected. 



SIMULATED DEAFNESS. 

There are various motives which lead to simulation of ear disease of 
one form or another. Hysterical individuals sometimes do it to excite 
attention or sympathy. Those drafted into the army or being in army 
service, and desiring to avoid duty, and those injured on railways, streets, 
and in shops sometimes exaggerate or assume or artificially produce ear 
disease, in order to collect damages through the courts. It is well, 
therefore, to briefly outline some of the methods for detecting malin- 
gering of this sort. 



SIMULATED DEAFNESS 863 

Tests for Simulated Deafness.— (a) First make a careful objective 
examinaiion of the external ear, external auditory meatus, drumhead, 
and the Eustachian tube. It is a significant fact that in the army 
most cases of suspected simulated deafness are unilateral. This arises 
from the fact that a double deafness would have previously attracted 
attention, whereas a one-sided deafness might have existed without 
having attracted attention. In other words, it is easier, on this account, 
to simulate one-sided deafness, hence its greater frequency among 
malingerers. The malingerer often artificially produces an obvious cause 
for the deafness he wishes to assume by dropping strong solutions of 
silver nitrate, carbolic acid, creosote, tincture of cantharides, etc., into the 
meatus. The skin and drumhead are thus cauterized and simulate in 
some degree suppurative otitis media. A careful examination will usually 
reveal the source of the inflammation. If silver is used, a dark-brown 
stain will be seen; whereas if carbolic acid is used, the bleached skin 
will aid in arriving at a correct conclusion. A bandage placed over 
the ear will in these cases lead to a speedy recovery, as the malingerer 
is unable to continue the caustic applications. Foreign bodies placed in 
the meatus to simulate deafness and ear disease may be detected by a 
careful examination. 

(6) It is in those cases in which there are no objective signs of ear 
disease that the real difficulty of detecting malingering arises. The 
would-be patient often studies the subjective signs of labyrinthine deaf- 
ness so well that, if he is especially shrewd, it is well-nigh impossible to 
detect him in the assumed deafness. In making the examination of this 
class of cases the eyes of the suspect must be bandaged, thus rendering 
it somewhat diflacult for him to judge distances in testing with the voice, 
acoumeter, or watch. If he hears the instrument at greatly varying 
distances with the deaf ear (the other being tightly plugged) it is fair 
to presume he is malingering. If, on the other hand, during repeated 
short testings, he hears at about the same distance, it is fair to presume 
that he is really deaf. 

(c) Erhard's Test. — Wlien a normal ear is tightly closed a loud ticking 
watch (the Ingersoll watch) may be heard at three or four feet. The 
patient should have the supposed deaf ear tightly closed, and when the 
watch is within three or four feet of the normal ear, he should be com- 
manded to count the beats, which he will, of course, readily do. The 
sound ear should then be closed, the supposed deaf one being open, and 
the same test made on the open deaf ear. If when the watch is within 
two or three feet of the ear he says he does not hear it, it is fair to 
presume that he is simulating the deafness, as at that distance he 
would hear the watcli with the closed normal ear. 

(d) Chimani-Moos Test. — In one-sided deafness a large vibraling 
c, fork is alternately held at an equal distance from each ear, until tlic 
suspected malingerer makes it j)lain to liiniself that he hears I lie fork 
loudest before the normal ear. The vibrating fork is then pl.iccd on 
the vertex, bridge of the nose, or median line of the incisor tcclh, und 
the patient is asked in which cnr he hears the fork tlic j)liiincsi. A 



SG4 THE EAR 

patient witli true middle-ear disease on one side will, without hesitation, 
say that it is plainest on the affected side; whereas a malingerer will 
hesitate, as he hears it equally well on both sides, or he may say he does 
not hear the fork at all in the suspected ear. The normal ear should 
now be tightly closed and the vibrating fork again placed on the median 
line of the skull, and the malingerer will probably say he does not hear 
it at all, or but faintly; whereas in true one-sided deafness the patient 
will say he hears the tone louder in the affected side. This only applies 
to disease, or simulated disease, of the conduction apparatus. If disease 
of the preception apparatus is being simulated, the problem becomes 
more difficult. 

{e) A common stethescope, having one tube closed with a wooden 
})lug, may be used to detect simulated unilateral deafness. The stetho- 
scope should be adjusted to the patient's ears, the open tube leading to 
the suspected ear, the closed one to the normal ear. The physician should 
now speak into the bell of the stethoscope, having the patient repeat what 
he hears. The instrument should then be removed, the normal ear tightly 
closed, and the same formula repeated to the patient. He will say he 
cannot hear, whereas he has already repeated after you, with the normal 
ear tightly closed with the plugged-arm of the stethoscope. In other 
words, he heard with his suspected ear through the open tube of the 
stethoscope (the one leading to the normal ear being closed with a wooden 
plug), thinking, of course, that he would lead the examiner to believe 
he heard with the normal ear. 

(/') The use of four ear specula, two open and two half filled with wax, 
may be used to detect malingering. The patient should sit with bandaged 
eyes facing the wall. The two open specula should be simultaneously 
introduced, one in each ear, and the examiner (behind the patient) 
should repeat certain words, or numerals, at varying distances, and 
thus ascertain his hearing distance with both ears open. He should 
then change the specula using one open and one closed, then two open, 
then two closed, and so on, noting the distances he hears with the vary- 
ing formulae of the specula. In this way the patient will unwittingly 
reveal the true condition of his hearing apparatus. 

Repeated examinations and the striking contradictions made by the 
malingerer during the various examinations will lead to a correct 
diao-nosis in most cases. 



PARESES AND PARALYSES. 

Angioneurotic Paralysis of the Auditory Nerve.— This is probably 
a rare affection, or, at least, it has been rarely recognized and described, 
and is characterized by a transitory facial pallor, nausea, dizziness, 
tinnitus, and deafness. The attack lasts but a few minutes, and when 
it disappears the hearing is perfectly normal. The attacks may occur 
at frequent intervals. 

The treatment consists in the administration of sedatives, tonics, and 



PARESES AND PARALYSIS 865 

the application of galvanism over the cervical sympathetics, which have 
an intimate anatomical connection with the terminal nerve endings in 
the labyrinth. 

Rheumatic Paralysis of the Auditory Nerve.— This is an obscure 
affection and difficult to diagnosticate. The diagnosis must largely depend 
upon the history of rheumatism elsewhere in the body, and upon the 
involvement of other cranial nerves. It may, however, in rare instances 
involve the auditory nerve alone. Bing reports a case limited to the 
auditory nerve, and the clinical picture was as follows : (a) Female, aged 
forty-seven years, exposed to a draught. (6) Complete deafness, and 
tinnitus in the right ear, the left being less affected, (c) Weber lateralized 
to the left ear. (d) Inflation of the middle ear did not increase the 
hearing distance, (e) The case ended in recovery in eight days from 
the internal administration of the iodide of potassium and the applica- 
tion of vessicants to the mastoid region. It should be remarked that 
in these cases there is an absence of the objective signs of middle-ear 
disease. 

Symptoms. — The symptoms are those given above, with the addition 
of the history of rheumatism elsewhere in the body, the involvement of 
the facial or other cranial nerves, and the signs of labyrinthine involve- 
ment, as lessened, or loss of, bone conduction. If the vestibular portion 
of the labyrinth is affected there will be dizziness or a staggering gait; 
whereas if the lesion is limited to the cochlear portion of the labyrinth, 
deafness and tinnitus will be the chief symptoms. 

Hysterical Paralysis of the Auditory Nerve. — This form of ear 
disease is usually unilateral, and is characterized by unilateral deafness, 
with tactile hypesthesia, hyposmia, contracted field of vision, and by 
diminished sensibility of the skin on the affected side. The Eustachian 
tube, drumhead, external meatus, and auricle are occasionally hypes- 
thetic on the affected side. Weber experiment: tone lateralizes to the 
normal ear, bone conduction being diminished on the side of the paralysis. 
\Wi.spered speech can often be heard at six or eight feet, while the tuning- 
fork may not be heard at all. This is considered by Hanunerschlag as 
characteristic of hysterical paralysis. The same observer calls atten- 
tion to the fact that a tuning-fork vibrating at its greatest intensity before 
the affected ear ceases to be heard, and then after a few seconds is 
heard again. This, he explains, is due to fatigue of the auditory nerve, 
which after a few moments' rest perceives the sound again (Politzer). 

Slight aural lesions in hysterical incHviduals may give rise to marked 
disturbance of hearing. Tinnitus and dizziness, however, are signs of 
organic labyrinthine disease. In hysterical deafness the degree of 
deafness varies greatly at different times. 

Treatment. — The treatment of hysterical deafness should embrace the 
relief of any middle-ear disease found, no niiider how slight in character, 
as great improvement, all out of j)r()j)()rti()ii to (lie iip})iin'nt lesion, often 
follows it. The nervous and general sysleiiis sliouKl be l)iiilt iij) by tonic 
and sedative remedies, outdoor life, bathing, etc. The iodonucleoid or 
the iodide of potash should l)e given in tlu'ee to six grain doses three 
55 



86G THE EAR 

times daily. Galvanism of the ear and sympathetic system of the neck 
may also be used to some advantage. 



NEUROSES OF THE AUDITORY APPARATUS; HYPERESTHESIA. 

1. Hyperacuteness of Hearing. — Oxyecoia is a rare form of hyper- 
esthesia, and is cliaracterized by a temporary ability to hear music, or 
at least certain tones, at a much greater distance than others do with 
normal hearing. It is usually caused by alcoholic and tobacco poisoning, 
and is especially prone to occur in hysterical and neurasthenic persons. 

2. Paracusis. — Paracusis may be due to a disorder of the nervous 
apparatus the labyrinth or to a disturbed tension of the drumhead and 
ossicles of the middle ear. In this condition there is a false interpre- 
tation of the pitch of a tone, often amounting to | to ^ interval. 

Paracusis duplex, or diplacusis, is a variety of disturbed perception of 
pitch, and is characterized by the hearing of two tones for every sound 
produced, or in certain cases only for certain tones. It is due to certain 
unknown influences in the course of acute otitis media, serous middle- 
ear catarrh, chronic suppurative otitis media, and hyperostosis of the bony 
capsule of the labyrinth. 

Paracusis Willisii is characterized by the ability to hear better in a 
noisy place, as on a railway train, street car, and a machine shop. Its 
etiology is still a mooted question, although it is commonly present in 
sclerosis of the middle ear and in hyperostosis. Some hold that the im- 
proved hearing in the presence of noise is due to the increased excitability 
of the terminal nerve filaments of the labyrinth, while others hold that it is 
due to the mechanical vibration of the bone and secondarily of the terminal 
nerve filaments, which increases their auditory power. Still others advance 
the theory that it is due to a shaking and loosening of the ossicles of the 
middle ear that accounts for the phenomena. The vibration of the cranial 
bones and the attending stimulation of the nervous apparatus and fluid 
contents of the labyrinth and cerebrospinal spaces seem to the author to 
be the most rational explanation. We know from personal observation 
that mechanical vibration applied to the spinal column and the head 
improves the hearing in some cases. Whether this is due to a stimula- 
tion of the nutritional centres, or to a stimulation of the nervous apparatus 
of the laljyrinth, is still an open question. We know also from personal 
observation that if these patients are placed in bed and given passive 
exercise (massage) and wholesome food for a few weeks, that their hearing 
will im])r()ve. 

.3. Hyperesthesia Acoustica. — This condition is characterized by a 
disagreeable sensation when musical tones or sounds are heard. The 
condition is usually present in anemic and hysterical individuals, and 
in those convalescent from severe illness. It may be present in certain 
forms of neuroses, as hemicrania and trigeminal neuralgia. It is also 
one of the manifestations attending the administration of cjuinine and 
salicvlic acid. 



NEUROSES OF THE AUDITORY APPARATUS 867 

4. Tinnitus Aurium, or Subjective Noises.— This is one of the 

commonest ear symptoms, and has been repeatedly referred to in this 
work in the descriptions of numerous ear diseases. Its exact etiology 
is obscure in spite of the large amount of literature on the subject. 
Various theories have been advanced, explaining its cause, the one by 
Shambaugh being the most lucid and satisfactory. 

He advances the interesting and ingenious theory that, "In the first 
place, the character of tinnitus aurium is usually that of an indefinite 
sound, like the wind in the forest or the rushing of water, sounds made up 
of a great complexity of tones and with no definite pitch. Clinically, these 
subjective sounds arise from a variety of pathological conditions. One 
of the best known causes of tinnitus is pressure applied to the conducting 
apparatus, so as to push the foot plate of the stapes into the oval window. 
This results in tinnitus aurium of the indefinite character described 
above. What actually takes place when the stapes is thus forced into 
the oval window is an increase in the pressure of the intralabyrinthine 
fluid. The result of this alteration in pressure must be a disturbance 
of the membrana tectoria (see Anatomy and Physiology of the Laby- 
rinth), which has apparently the same specific gravity as the endolymph 
when the latter is under normal pressure. The hairs from the hair 
cells, as I have shown, normally penetrate into the lower surface of the 
membrana tectoria. Any disturbance in this membrane, however 
slight, would, therefore, alter the normal relations existing between the 
membrane and the hair cells. It seems that such an alteration from 
the normal relation between membrana tectoria and the hairs of the hair 
cells would constitute a stimulation of these cells. When the foot plate 
of the stapes is pushed into the oval window there would result a slight 
stimulation of perhaps all the hair cells in the cochlea. The result 
would be exactly what we meet with clinically, a tinnitus aurium of an 
indefinite character, like the wind in the forest or the roar of a sea-shell. 
When a sudden increase or decrease in the blood pressure results in 
tinnitus aurium the cause is the same as when the stapes is pushed into 
the oval window. The explanation for the increase or decrease of the 
intralabyrinthine pressure is here quite evident. The tinnitus aurium 
arising from the administration of certain drugs is also plausibly explained 
in the same way as due to an alteration in the blood supply to the laby- 
rinth with resulting alteration in the pressure of the intralabyrinthine 
fluid. The tinnitus occurring in Meniere's disease, where there has been 
an escape of blood into the cochlea, is also similarly accounted for by 
this conception of the physiology of tone perception. The disturbances 
in the function of hearing arising from an injury produced by a shrill 
whistle, or an explosion near the ear, are also readily explained. In the 
first place, when a permanent disturbance in hearing is thus produced, 
it can be readily accounted for by a partial severance of the relation 
between the membrana tectoria and hair cells, so that the hairs from a 
greater or smallci- iiiiiiitx-r of ihcsc cells project free in the en(lolymj)h 
and do not conic in conhicl willi (lie membrana tectoria, and therefore 
caiuiot receive (lie s(iniiil;ili()ii IVoiii iiiipiilscs piissiiiu,- (lirouu'li (he cndo- 



S(38 THE EAR 

lymph. On the other hand, when there resuUs from such an injury a 
permanent tinnitus aurium, this is explained by a partial, not complete, 
severance of the membrana tectoria from the hair cells over a certain area. 
This alteration of the relation existing normally between the hair cells and 
membrana tectoria may result, as we have repeatedly pointed out, in a 
stimulation of these cells. This explanation appears all the more 
rational since the pitch of the tinnitus is often approximately that of the 
whistle which originally produced the injury." 

The external conditions which influence tinnitus are those which 
influence catarrhal diseases of the upper respiratory tract, namely, 
sudden changes in the weather and temperature, living in damp places, 
improper clothing, etc. Bodily conditions, as fatigue, exhaustion from 
heat or undue exposure to inclement weather, and bodily depression 
from overmen tal application, also aggravate the subjective noises. 

The character of the noises is as various as noises themselves, the 
usual form being a singing, whisding, chirping, popping, crackling 
sound, or like the noise of a railway train in the distance. Many other 
noises are described by patients. They may be intermittent or continu- 
ous. The remissions usually occur while the patient's mind is engrossed 
with other matters, hence they are less troublesome in the daytime. 
Some patients are so distressed by the noises that they are driven to 
desperate measures, even to suicide. 

In some cases the noises increase in proportion to the deafness, in 
others they cease with marked deafness, while in still others they continue 
to increase after the deafness is absolute. They may appear in persons 
who are not deaf, but who are nervous, or exhausted from overmental 
or physical exertion, or from grief. 

The Hearing of Voices and Music. — Human voices and musical 
melodies are sometimes heard by persons who have some affection of 
the cortex of the brain, though rarely or never by subjects with an 
uncomplicated ear disease. An existing ear disease may aggravate 
the condition existing in the cortex of the brain, hence the cure of the 
ear disease is often attended by an improvement of the hallucinations. 
Some persons hear musical melodies repeated over and over, and are much 
annoyed thereby. The subjective hearing of human voices is more 
serious, and often the forerunner of melancholia, or progressive paralysis. 

Prognosis and Treatment. — The prognosis and treatment of tinnitus is 
embraced in the various diseases in which it occurs as a symptom. It 
may be said in general, however, that it is comparatively good in those 
cases of simple middle-ear and tubal catarrh, that it is more unfavorable 
in hyperostosis and labyrinthine diseases, in noises of cerebral origin, and 
where the arterial noises have existed for a long time. Paracusis 
Willisii is usually taken to indicate a well-marked sclerosis of the middle 
ear, hyperostosis of the bony capsule of the labyrinth, and the prognosis 
is unfavorable except where suitable remedial measures are used early. 
In those cases in which human voices and musical melodies are heard 
the prognosis is very grave, except in those rare cases in which the relief 
of the noises follows the cure of the middle-ear disease. 



DEFECTS OF HEARING DUE TO INTRACRANIAL TUMORS 869 

The treatment of subjective noises is as broad as the subject of ear 
and brain diseases themselves, hence further consideration will not be 
given to it here. 

WORD-DEAFNESS OR SENSORY APHASIA. 

This form of deafness is characterized by the ability to hear, with the 
loss of the power to distinguish words, and is thought to be due to 
a lesion of the cortex in a portion of the middle convolution of the left 
temporal lobe, or in the left gyrus of that lobe. It may be questioned, 
however, whether the auditory (acoustic) centre is so restricted in its 
distribution. ^Mien present, it is generally due to an encephalitis, an 
exudate following a hemorrhagic pachymeningitis, brain tubercle, or to 
an embolic softening of the brain, 

T5rpes of Word-deafness. ^ — (a) Amnesic aphasia is characterized 
by the loss of memory for things, or the patients call objects by their 
wrong names, (b) Monophasia consists in the naming of all objects 
to which the attention is directed by the same name, (c) Amnesic 
agraphia is an inability to write the words spoken to the patients, or the 
names of objects placed before them, (d) Still others hear and under- 
stand what is said to them, but are unable to repeat it. (e) Amusia is a 
term introduced by Knoblauch to indicate deafness for musical tones. 
It occurs more frequently than word-deafness, and is probably due to a 
lesion of the first and second convolutions of the left temporal lobe in 
right-handed persons. Word-deafness and tone-deafness may exist at 
the same time. In tone-deafness the amusia varies in degree from abso- 
lute loss of hearing for musical tones to false interpretations of them. 



DEFECTS OF HEARING DUE TO INTRACRANIAL TUMORS. 

Brain tumors, especially of basilar origin, may give rise to disturb- 
ances of hearing by pressure upon, or stretching of, the auditory nerve 
fibers, and by giving rise to an ascending neuritis of the auditory nerve. 
A lymph stasis at the origin of the auditory nerve may also cause aural 
disturbances (Gradenigo). This condition is similar to that which 
occurs in the optic papilla during an increase of intracranial pressure. 

Symptoms. — The symptoms are unilateral tinnitus aurium, and 
deafness, more or less complete, and dizziness. Other symptoms, not 
expressed througli the auditory apparatus are a feeling of tightness in 
the head, ghmniering or (hill vision, pain or full feeling on the side of the 
head corresponding to the location of the tumor, slow pulse, choked 
disk, motor and sensory paralysis over the areas supplied by the other 
cranial nerves, which are also usually more or less involved. 

Diagnosis. The diagnosis must be mkkIc diicdy by the disturb- 
ances arising tlii'oiigh the lesions of the other ci-aiiia! nerves, as the 
aural symptoms ai-i- not ehanicteristic of this form of ear disease. An 
early diagnosis cannot, therefore, often i»e niach'. Facial paralysis and 



870 THE EAR 

retained perception for the tuning-fork, watch, and acoiimeter through 
the cranial bones, together with dizziness, tinnitus, and deafness, are 
significant symptoms. The perception of the forks, watch, etc., through 
the cranial bones exclude labyrinthine disease, even of a mild type. The 
perception for high tones often remains unaffected, wdiile in some cases 
it is diminished. The age of the patient should be taken into account 
in connection with the tests of bone conduction and the hearing for high 
tones. If the patient is more than fifty years old there is a physiological 
diminution in the perception by bone conduction, as well as a restric- 
tion of the upper limit of hearing. Hence, in a case with the above aural 
symptoms, in which there is a suspicion of brain tumor, the presence of 
a slight diminution of hearing by bone conduction and the loss of hear- 
ing for the higher tones would not necessarily lead to the conclusion that 
the labyrinth was affected by the presence of a brain tumor. As first 
stated, the chief diagnostic guide is the pareses or paralyses of the other 
cranial nerves, the facial nerve usually affording the most direct and cer- 
tain information. A slight paresis and anesthesia of the skin over the 
area of nerve distribution, when found in conjunction with deafness, 
tinnitus, and dizziness, usually point strongly to an ear disturbance 
having; its origin in tumor of i\\Q brain. 



NEOPLASMS OF THE INTERNAL EAR. 

New-growths in the internal ear may be primary (rare) or secondary. 
Primary growths at the root of the acoustic (auditory) nerve have been 
reported, but nearly all accurately reported cases have been secondary. 
Epitheliomata and malignant round-cell sarcomata may extend from 
the middle ear to the labyrinth, and destroy the cochlea, vestibule, or 
even the whole of the petrous portion of the temporal bone. Neuromata 
of the auditory (acoustic) nerve have also been observed. Cavernous 
angiomata of the petrous portion of the temporal bone has been reported 
by Politzer, and is extremely rare. 

The symptoms vary with the location and size of the growths, and are 
deafness, tinnitus, dizziness, staggering gait, nausea and vomiting, 
together with other extraneous symptoms due to lesions of the other 
cranial nerves. 

LOCOMOTOR ATAXIA DEAFNESS. 

Disturbances of hearing occurring in the course of locomotor ataxia 
are due to an atrophy of the auditory nerve. The atrophy may affect 
the nervous apparatus anywhere from its cortical origin to its distri- 
bution in the labyrinth. According to various statistical reports, the 
hearing is affected in tabes dorsalis in from 1 to 80 per cent, of the cases 
recorded. The aural symptoms develop gradually, seldom rapidly. 
The tinnitus is always present and almost unbearable. The affection 
is usually bilateral, and dizziness is present in about 65 per cent, of the 



LOCOMOTOR ATAXIA DEAFNESS 871 

cases. The author recently examined a case in which there was deafness, 
intolerable tinnitus, and dizziness. The bone conduction and upper 
range of hearing were diminished, but not more than the age of the 
patient (sixty-five years) would account for. Rotating the head on its 
various axes with the eyes closed did not increase the dizziness. The 
appearance of the drumheads was normal. The hearing for low, 
deep-toned tuning-forks was normal, Rinne negative, and both ears 
were affected. 



CHAPTER LI. 

DEAF-MUTISM. 

HoLGER iMygind's elaborate and classical treatise on deaf-mutism 
opens with the following paragraph: 

"Definition. — Deaf-mutism, strictly speaking, signifies the abnor- 
mality which is characterized by the co-existence of deafness and 
dumbness. Various circumstances necessitate, however, a more limited 
definition. Deaf-mutism may, therefore, be defined as a pathological 
condition dependent upon an anomaly of the auditory organs, either 
congenital or acquired, in early childhood, causing so considerable a 
diminution of the power of hearing as to prevent the acquisition of speech; 
or, should speech have been acquired before the occurrence of the loss 
of hearing, it is preserved by the aid of hearing alone. Individuals 
exhibiting this pathological condition are described as deaf-mutes, even 
when speech has been acquired by a special system of instruction." 

The foregoing definition will be observed in the consideration of this 
subject. 

Historical. — It is interesting to know, as ]\Iygind has shown, that 
deaf-mutism has been referred to in literature from the time of Exodus 
(fourth chapter and second verse) was written. Herodotus, Hippoc- 
rates, Aristotle, Pliny, Gellius, and others of the ancient period refer 
to it. 

Cananus, Pedro de Ponce, Andreas Laurentius, and Zachias refer to 
it in the Middle Ages. 

A gradual change of opinion as to the relationship between hearing 
and speech took place. In the ancient period the idea prevailed that 
it was due to the inability to use the tongue (Hippocrates and Aristotle). 
Later, Pliny said, "The man who is born without the power of hearing 
is also deprived of the power of speech, and none are born deaf who are 
not also dumb." 

During the Middle Ages the influence of Aristotle's writings were so 
potent that little progress, beyond the opinion expressed by him, was 
made. Cardanus, 1501 to 157G, first distinctly stated the true relation- 
ship, i. c., that deafness is the princijial and primary cause of deaf- 
mutism. 

During the last century the subject was placed upon a scientific 
basis, chiefly through the writings of Itard, Schmalz, Wilde, Meissner, 
Toynbee, von Troltsch, A. Hartman, I^emcke, and Mygind. 

It is true that institutional w^ork and statistical bureaus have aided 
very materially in the evolution of the subject. The classical work of 
]\Tygind probably re})resents the most advanced and correct statement 



DEAF-MUTISM 873 

on the subject that has been given, and it is chiefly from his work that I 
glean the data for this chapter. I also refer directly to the works of 
von Troltsch and Toynbee. 

Classification. — Deaf-mutes may be classified according to the 
degree of deafness as : 

(a) True deaf-mutes, or those who are totally deaf to speech, and 
must depend entirely on the other senses to acquire its use. 

(6) Semi-deaf-mutes, or those who have slight power of hearing, or 
who retain slight speech acquired before deafness supervened. 

Some confuse those who, for other reasons than deafness, have lost the 
power of speech with deaf-mutism. It should, therefore, he distinctly 
understood, without question, that deaf-mutism refers to those who have 
lost or failed to acquire speech on account of deafness. 

Another classification, which is perhaps better as a practical working 
basis, is that adopted by Mygind, namely : 

(a) Congenital deaf-mutism. 

(b) Acquired deaf-mutism. 

The first class refers to those who are born with some defect of the 
organ of hearing, which, according to modern statistics, includes about 
50 per cent, of all the cases. Mygind thinks this estimate too high, as 
many of the so-called congenital cases are, in all probability, due to some 
intercurrent disease of the ear which destroys the hearing before articu- 
late speech is acquired. While my observations have been compara- 
tively limited, I have nevertheless seen enough of these cases to know 
the difficulties to be encountered in determining whether some of them 
belong to the congenital or to the acquired class. I am, therefore, 
inclined to coincide with Mygind in thinking that 50 per cent, is too high 
an estimate to be placed upon the relative proportion of congenital as 
compared with the acquired types of deaf-mutism. 

The relative 'proportion of deaf-mutes to the total population of the 
various countries in which statistics are to be found varies from 34 
(Holland) to 245 (Switzerland) per 100,000 inhabitants. The average in 
European countries is 79, while in the United States it is 68 per 100,000 
inhabitants. 

Etiology. — The great variations in the relative number of deaf-mutes 
in the different countries seems to point to certian localities as pre- 
disposing to it. Old geological (Escherich) formations, as found in the 
Alps, were formerly thought to be the cause, but more careful investiga- 
tions have sliown this to be incorrect. Social and hygienic (H. Schmaltz) 
conditions peculiar to tlie various countries more nearly account for the 
great variations. In Switzerland, where the rate is so high, it is due to 
the endemic cretinism so prevalent there. This type of deaf-mutism is 
not included in the consideration of this subject. 

Climate probably has no influence. 

Unfavorable social and Jiggioiic conditions piny a very iniportMiit j);irt 
in the causation of deaf-mutism. 

II. Schmaltz emphasizes this in his work <>ii (Icnf-nmtisni in Snxony. 
In conclusion he says: The industrial popnhition, and ("specially that 



874 THE EAR 

part of it which is worse off from a pecuniary point of view — in fact, all 
who are in danj^er of degenerating both morally and physically on 
account of insufficient means, or poverty, and who, consequently, are 
unable, or unwlling, to take the necessary care of their children — all 
such persons exhibit the highest percentage of deaf-mutes among their 
descendants. Finally, we found that when, in addition to all these 
unfavorable conditions under which children are born, they are brought 
up l)y a family which, from various reasons, is perhaps already more or 
less degenerated, and have to undergo all sorts of diseases in infancy 
without having sufficient power of resistance, then deaf-mutism is an 
only too common result." 

Heredity undoubtedly influences the number of deaf-mutes. Mygind 
very tersely expresses the present status of our knowledge on this point 
in the following words: "Deaf-mutism is comparatively frequent among 
the relatives of the deaf-mutes; it is least frequent in the direct ascend- 
ing line (grandparents, parents); more frequent in the collateral 
branches (great-mi cle, great-aunt, uncles, aunts, grandparent, cousins, 
])arents' cousins, and second cousin) ; and most frequent by far among 
the brothers and sisters of the deaf-mutes. This is in exact accord- 
ance with the result of an investigation into the appearance of deaf- 
mutism among the relations of congenital deaf-mutes; therefore, and 
from many of the facts above mentioned, we are justified in supposing 
that the manner in which deaf-mutism appears in different generations 
is a result of certain qualities appertaining to its congenital form." 

It is not assumed that deaf-mutism p^r ^e is transmitted by hereditary 
influences, but that certain anatomical or nervous states are retained to 
some extent, and that these may result in deaf-mutism — that is, deaf- 
mutism is influenced by the transmission of a predisposition to certain 
ear diseases and to certain nervous disorders. These, in combination, 
tend to produce deaf-mutism. 

Consanguineous marriages seem to influence the number of deaf- 
mutes, as is shown in the following table : 

FOKTY-SEVEN MaRRIAGES BETWEEN BlOOD RELATIONS PRODUCES SeVENTY-TWO 

Deaf-mutes. 

1 marriage between aunt and nephew produced 3 deaf-mutes. 

4 marriages " uncle and niece " 11 " 

26 " '■ first cousins " 38 " 

16 " " second cousins " 20 " 

Statistics go to prove that the influence of consanguineous marriages is 
entirely limited to congenital deaf-mutism. 

Various diseases in parents, as alcoholism, syphilis, general debility, 
epilepsy, insanity, etc., are etiological factors in the production of deaf- 
mutism. The offspring of such parents do not receive in utero the vital 
energy necessary to resist the vicissitudes of life after birth. They are, 
therefore, more liable to be injured by infections and nervous diseases 
than the offspring of healthy parents. It may be said in this connec- 
tion, however, that the parents of deaf-mutes are often remarkably 
liealthv and robust individuals. 



DEAF-MUTISM 875 

Hemophilia and deaf-mutism are rather commonly associated among 
the offspring of marriages producing a large number of children. 

The death rate is higher among children in families in which there are 
deaf-mutes, probably on account of the stigmata of degeneracy, and 
because suppurative otitis media adds to the mortality rate. 

Mygind cites statistics to show that first births produce more deaf- 
mutes than either the second, third, fourth, or fifth. Other weaknesses 
are also more common among the first born. 

Maternal impressions do not appear to exert a marked influence in the 
production of deaf -mutism. 

Having considered some of the remote causes of deaf-mutism, we will 
next turn our attention to the more immediate causes. 

Immediate Causes of Deaf-mutism. — The age at which most cases 
of deafness occur in the acquired type is from the first to the fifth years, 
more occurring in the second and third years. In the United States the 
greater number occur in the third year. 

Brain diseases, more particularly simple meningitis and epidemic 
cerebrospinal meningitis, are the chief causes of the acquired deaf- 
mutism. From 12 to 26 per cent, of the European cases have been 
attributed to epidemic cerebrospinal meningitis. Moos and Knapp 
were the first to call attention to this disease as one of the causes of 
deaf-mutism. 

Deafness may occur during epidemic cerebrospinal meningitis resulting 
from middle-ear or labyrinthine lesions. The former occurs more often, 
but is not so pronounced nor so permanent as that due to the involve- 
ment of the labyrinth. Deafness of middle-ear origin does not so 
often produce deaf-mutism on this account. Labyrinthine involvement 
usually occurs about the second week of epidemic meningitis, although 
it may occur at a much later period (Knapp, Mygind). The deafness 
occurs suddenly, in contradistinction to that in middle-ear deafness. 
Postmortem examinations have shown most of them to be due to inflam- 
mation of the membranous labyrinth. "This process leads partly to the 
more or less complete destruction of the contents of the labyrinth, and 
partly to regeneration of tissue. This new tissue may be either fibrous, 
calcareous, or osseous, and may fill the normal cavity of the labyrinth 
either completely or partially" (Mygind). 

The original cause of the disease is undoubtedly some microorganism 
which enters through the ear, nose, or epipharynx, although definite 
data is not yet at hand to confirm this statement. 

The equilibrium is often disturbed in deafness due to brain disease, as 
pointed out by Moos. This is due to the involvement of the semi- 
circular canals and other apparatus of tlie labyrinth. This may endure 
for years. 

Other aciifr 'mfrdious diseases, as scarlet fever, measles, typhus and 
typhoid fevers, di{)litlieriii, smallpox, vaccination, (■lii(ken-{)()x, erysij)e- 
las, dysentery, influenza, malaria, whoo|iing-c()ngli, mumps, croupous 
pneumonia, and I'lieiimatic re\-er dii-eclly oi' indirectly cause infantile 
deafness. The inliaumiation (irsl aUack^ the mucosa of the middle eai-. 



876 THE EAR 

whicli ulcerates, the bone beneath becomes carious, and the meninges 
and hd)vrinth are thus exposed to infection. The ossicles of the middle 
ear, being covered by the mucous membrane, imdergo the same changes. 
If the destructive changes do not involve the labyrinth, the deafness is 
not usually profound enough to cause deaf-mutism. If it involves the 
labyrinth, the same changes described under cerebrospinal meningitis 
take place and result in complete and permanent deafness. If this 
occurs before speech is acquired, the child becomes a deaf-mute. 

In scarlet fever, measles, and kindred diseases the infection enters the 
tympanum through the Eustachian tube. The labyrinth is usually 
invaded through either the oval or round windows, as has been shown 
in numerous autopsies by the scar on the membrane. In some cases, 
however, it appears that the middle ear is not involved at all, the drum 
membrane being normal. It is probable in these cases that the infection 
reached the labyrinth by metastasis. 

Smallpox does not account for many cases of deaf-mutism in those 
countries where compulsory vaccination is in vogue. It is barely pos- 
sible that vaccination is a cause of deaf -mutism. 

Connor collected the literature of labyrinthine diseases caused by 
mumps up to 1884, and found 33 cases, 9 of which w^ere fifteen years of 
age or less. 

Certain constitutional diseases, more particidarly syphilis, scrofula, 
and rickets, are occasional causes of deaf-mutism. Inherited syphilis 
causes it more often than is shown by the statistics, as it is difficult to 
ascertain the data concerning this affection. 

Fright, lightning-stroke, sunstroke, quinine poisoning, colds in the 
head, sudden immersion in water, and trainuatisms occasionally cause 
deaf-mutism. One or more of the foregoing conditions, singly or com- 
bined, cause acquired deaf-mutism. They have been given without the 
full data to confirm them, as the scope of this volume will not permit. A 
fuller knowledge of the causes of deaf-mutism should be prevalent 
among physicians, as it is to them the parents will first appeal for infor- 
mation and relief. Many of these cases may be so educated as to make 
them useful members of society and a source of gratification to them- 
selves and to their parents, if the needed advice or attention is given 
them at the proper time, i. e., while their minds are still in the imaginative 
and perceptive stages of development. (See Lip Reading.) 

Pathology. — Reliable postmortem examinations in 139 cases of deaf- 
mutism are on record. From these the following facts are gleaned 
(Mygind) : The changes in the external ear and the auditory meatus will 
not be considered, as they could have but little to do with the causation 
of deaf-mutism. In the drumhead, perforations, calcareous deposits, 
adhesions, thickening, and entire absence have been found. 

In tiie middle ear adhesive processes, calcifications, and ossification 
from intense inflammation have been found. The oval window is some- 
times filled in with a mass of bony tissue (hyperostosis), while the round 
window is contracted in size. The membrane of the round window is 
sometimes thickened, or thinned, scarred, calcareous, or absent. 



DEAF-MUTISM 877 

Osseous masses in the attic and other portions of the middle-ear cavity 
are found. Caries of the bony walls of the middle ear from chronic 
suppurative inflammations are present in some. 

The ossicles are ankylosed, bound down by adhesions, necrotic, or 
entirely destroyed, from suppurative inflammatory processes, in a con- 
siderable number of cases. One or more of the ossicles may be absent, 
and the others present, the stapes alone being absent in a number of 
cases. 

When atrophy of the ossicula auditus is present, it is probably of 
congenital origin. 

Ankylosis of the ossicles is very commonly present. 

Atrophy and caseous degeneration of the tensor tympani and stapedius 
muscles is often present. The chorda tympani nerve is also sometimes 
absent. 

The mastoid process is found to be affected, as elsewhere described 
under suppurative diseases of the middle ear and mastoid process. It 
is sometimes absent from arrested development. 

The Eustachian tubes are sometimes obstructed by fibrous or osseous 
tissue, as a result of repeated inflammations. 

The Labyrinth. — The most frequent pathological change found in the 
labyrinth is the deposit of osseous tissue from inflammatory processes. 
This is sometimes so extensive as to completely obliterate the labyrin- 
thine canals (Mygind), and has given rise to the idea that there was 
congenital absence of the labyrinth from arrested development (Montain, 
Michel, Schwartze, Moos). Chalky pigment and fibrous deposits are 
also found. 

Absence of the auditory nerve and labyrinth (partial or complete) are 
also reported. In one of Mygind's cases the labyrinth was completely 
filled with osseous tissue, except at certain portions where pus was 
present. It was due to a suppurative process following scarlet fever. 

The membranous labyrinth may be congenitally absent, as shown by 
Nuhn. 

The vestibule (excepting its aqueductus) is rarely involved, even in 
congenital cases. When present, the changes are inflammatory in 
origin. Pathological changes in the contents of the membranous vesti- 
bule have often been found. 

The aqueductus vestihuli may be disteiidcd, in which case the cochlea 
is also affected (Ibsen), while the acjueductus is not affected, thereby 
suggesting an intimate relation between the acjucductus and cochlea 
rather than the vestibule. Ilabernuum explains the distention of the 
aqueductus vestibuli as being due to j)ressure in hydrocephalus, espe- 
cially when the petrous portion of the temporal bone is rachitic. 

'^rhc snnicircnlar canals are (|uite connnonly afl'cctcd. 

Symptoms. — Drafurss may be j)artial or (•()m])lc(c. If partial, tJKMV 
may be hrariin/ for sounds, noises, voic<', or speech. ( )nc child, for 
example, may hear a loud noise and not hear sj)eech, or cicc rcrsa: or 
he may hear the voice and not hear articulate speech. Again, he may 
hear tones of a certain pitch and not hear those of another pitch. 



878 THE EAR 

As stated in tlie be^inninp; of this chapter, the best classification is 
(a) true deaf-mutes, and (6) semi-deaf-mutes. In other words, into 
those who have partial hearing and those who have total absence of 
hearing. It is often difficult to determine this point in young infants, for 
obvious reasons. In older ones it can be usually done by the use of 
bells, loud whistles, clapping hands, etc. The child will blink the eyes, 
or show by a change in its expression that it hears. 

A more accurate method of testing older deaf-mutes may be made 
with tuning-forks and whistles. They should be tested for hearing by 
both air and bone conduction. Hearing by air conduction is tested by 
holding the vibrating fork near the external auditory meatus and noting 
the expression of the child; bone conduction is tested by placing the 
handle of the vibrating fork on the mastoid or the vertex of the head, 
the expression of the child being meanwhile watched for signs that he 
experiences a novel sensation. Other instruments, as the watch and 
the Politzer acoumeter, may be used if there is considerable hearing 
present. The voice, especially the articulate vowels, are used, being 
spoken close to the patients' ears, care being exercised to prevent them 
seeing the movements of the lips. If they hear the vowels, consonants 
and words may also be utilized for this purpose. 

Semi-deaf-mutes hear better at times than others, for the same reasons 
that those with less pronounced middle-ear disease have variations in 
hearing. 

The various reports as to the relative number of the totally deaf 
and partially deaf in the various statistical publications are not reliable, 
as different tests have been used to determine these facts. There are 
more cases of profound or total deafness among the acquired than the 
congenital cases, probably on account of the greater severity of postnatal 
processes in the ear. 

A very significant fact has been announced by Urbantschitsch, namely, 
that children who had previously reacted to no sound whatever, after 
having been subjected to certain acoustic exercises, were capable of 
hearing. This points to the fact that a sensory tract is developed by 
use. Its powers, or functions, may lie dormant for years, and then be 
aroused to activity and development. The fact that a child never has 
heard is not necessarily proof that it never will. 

Mntism may be the result of the deafness, or it may be due to the 
same influences which caused the deafness. There may be an arrested 
or perverted development of the vocal organs, coincident with the dis- 
turbed development of the ear; or aphasia may be due to a congenital 
or acquired lesion of the brain. If the speech centres of the brain are 
injured at the same time the ear is affected, the child can never be taught 
to speak clearly. 

The age at which deafness must occur to produce mutism is not to 
l)e stated arbitrarily, as the capacity to learn speech varies greatly in 
different children. Hartmann says that if deafness occurs before seven 
years of age, mutism is apt to follow. The slight speech already 
acquired will gradually disappear unless special pains are taken to 
cultivate the faculty of speech. 



DEAF-MUTISM 879 

The speech of deaf-mutes is peculiar, lacking in proper accentuation, 
which renders it monotonous. The respiratory act is deficient, and 
the voice feeble. The greater the deafness the more pronounced 
the peculiarities of the speech become. True deaf-mutes, as well as 
semi-deaf-mutes, may be taught articulate speech, which is known as 
"articulation." Deaf-mutes experience great difficulty in retaining 
"articulation" when they leave the school-room and mingle with those 
who can scarcely understand them. Articulation is quite different from 
ordinary speech, and it is only after hearing it used to a considerable 
extent that one learns to understand it. This is one of the difficulties in 
the way of its more general use among deaf-mutes. Lip reading is 
learned at the same time as articulation, but, as it requires close atten- 
tion and good sight, it is also often abandoned when contact with the 
world at large is established. 

Other ear symptoms, as tinnitus, giddiness or staggering gait, and 
otorrhea, are present in a certain number of deaf-mutes. Otorrhea is 
quite common, especially among the acquired cases. 

SequelaB. — An impairment of the mental faculties may or may not 
be present. ^Vhen it is remembered that a deaf-mute is barred from 
many avocations, it is easy to understand that ambition is thereby hin- 
dered in its expression. The temptation to idleness and dependence 
upon those more fortunate than himself often stultify his physical and 
mental and moral faculties. The morbid processes causing the deafness 
may also impair other portions of the brain, and thus impair the mental 
faculties. About 50 per cent, of those who are deaf-mutes are notably 
deficient in mental power. 

The laryngeal muscles are slightly atrophied from non-use in deaf- 
mutes; otherwise the larynx is usually normal. 

The lungs of deaf-mutes seem to be less resistant than those of other 
children, as shown by the fact that so many of them die of tuberculosis. 
This is still further shown by stethoscopic examinations. Their breath- 
ing is more superficial and less rhythmical than in normal children. 
This is true of those who have defects of speech, as stammering, with 
normal ears. 

Tuberculosis, scrofula, sterdtiy, ieft-liandedness, and diniimition of 
muscular energy are quite commonly found among deaf-mutes. 

The auricle is rarely malformed in deaf-mutes, as it develops inde- 
pendently of the internal ear. The external meatus and meiiibraiia 
tympani show such changes as are incident to middle-car diseases 
in general. ''J^he same is true of the Eustachian (uhcs and mastoid 
processes. 

Adenoids and catarrhal all'cclions of (he nose and cpiphai-viix <lo not 
seem to be more connnon anions' (h'af-mnlcs dian in odirr {■liiMrcn. 
That there is a (Hrcct relation hclwccn inlVcdon-. which cnlcr the 
middle ear thi-oiigh the e))ipharynx and Mnslachian tnlx's \\\vvv can lie 
no doubt. 'J'he same ii'i-itation causes die a<li'noid d>sne lo enlarL;-e, a 
fact which exjjlains tli<' apparent edolouical i-ehi honship oT adenoids to 
deaf-mutism. 



880 THE EAR 

Boucheron advances the ingenious theory that deaf-mutism may be 
caused })y otopiesis, meaning thereby deafness by "producing exhaustion 
of the air in the middle ear as the result of the closing of the catarrhally 
affected Eustachian tube, which process, again, causes overpressure in 
the inner ear, and consequently degeneration of the terminations of the 
auditory nerves" (Mygind). 

There are other abnormalities coincident to deaf-mutism, as of the 
cranium, the eye (retinitis pigmentosa, hemeralopia, "hen-blindness," 
panophthalmia, etc.), thyroid gland, nerves, and bones. They are 
largely the result of the same influences which primarily cause deaf- 
mutism. 

The relationship between idiocy and deaf-mutism is not that of cause 
and effect, as they are both the result of the same primary influences. 
Deaf-mutism does not cause idiocy. 

Insanity is estimated (Wines) to be four times as common among 
deaf-mutes as in individuals in general. jMygind'shows that this is prob- 
ably due to the isolated social position and mental depression, which 
naturally attends the loss of one of the chief senses. 

Diagnosis. — The diagnosis is easy in most cases, and is based on the 
following facts: 

(a) Deafness so pronounced that speech cannot be heard. 
(6) Deafness dates from birth or before the seventh year. 
(c) Deafness and fragmentary speech (semi-deaf-mutes). 

In infants it is difficult to make a diagnosis, as the infant does not yet 
speak, and it is difficult to determine if it hears. Loud bells, clapping 
of hands, whistles, etc., should be used without letting the child see them, 
noting the blinking of the eyes or other signs that it has recognized the 
noises. A negative result is not, however, conclusive of deaf-mutism. 
Hartmann has called attention to the fact that some children do not have 
the organ of hearing fully developed at birth, the development being 
completed at the first year of extra-uterine life. 

Simple mutism (aphasia) may be mistaken for deaf-mutism upon 
casual examination, although it is seldom congenital or acquired in 
infancy. Examination will show that hearing is present. 

Simulation of deaf-mutism and hysterical deaf-mutism are rarely seen. 

Prognosis. — A few well authenticated cases are recorded in which 
the hearing was improved. The great majority, however, are not 
thus favorably affected. The number of cases reported by men of the 
highest standing, as being so much improved that they regained enough 
hearing to carry on conversation with their fellows, warrants the use of 
every means within our power to alleviate all ear affections, with the hope 
that those under our care may also be thus favorably influenced. Some 
cases vmdoubtedly improve spontaneously. 

Speech will generally improve in proportion to the improvement in 
hearing. 

Treatment. — The treatment should be such as would be given to 
similar ear affections in those who are not deaf-mutes. Suppurative 
disease should receive special attention, to prevent it spreading to 



LIP READING 881 

neighboring organs. Postnasal adenoids and other diseased processes 
of the nose and throat should receive appropriate attention according to 
the methods described elsewhere in this work. 

After having done all that can be done to improve the organ of hear- 
ing and the general system, the child should be sent to some institution 
of reputable standing, where he can receive suitable training in the 
acquirement of speech or other means of communication. Here he will 
also receive instruction in useful knowledge and manual training, which 
will fit him for a place in social life. 

The prevailing methods of instruction are known as the German and 
French methods. The first is probably the best for a majority of deaf- 
mutes, as it teaches them articulate speech. There seems to be no 
doubt that the use of the vocal organs stimulates the development of the 
brain and motor tracts. Makuen has called attention to this fact. 
(See Defects of Speech.) The French method teaches communica- 
tion by means of signs. This is probably well adapted to some cases. 
The question of methods should, however, be left to those who are more 
intimately concerned to decide. It is not the physician's province to 
train these unfortunate children. His duty is to relieve the physical 
conditions as nearly as possible and then recommend the parents to send 
the child to some reputable institution for deaf-mutes, assuring them 
that only in this way will he be fitted for a useful place in society. 



LIP READING. 

Deaf-mutes, and persons so deaf as to understand conversation with 
difficulty, should be taught lip reading whenever possible. It has long 
been known that persons partially deaf watch the face of the one address- 
ing them, and, by combining what they imperfectly hear with the move- 
ments of the lips, the facial expression, and the gestures of the speaker, 
they are enabled to understand what was being said. This suggested 
the advisability of reducing lip reading to a scientific basis, and schools 
for this purpose are now established in nearly all large cities. 

The acquirement of facility in lip reading necessitates the closest 
application on the part of the student, and the most painstaking and 
persistent effort on the part of the teacher; hence, there is little hope of 
success outside of a special institution for this purpose. The physician 
cannot give adequate attention to such patients, and he should recom- 
mend that they be sent to a school at as early an age as possible, as 
orthewise the patient will be greatly handicapped in the pursuit of his 
b^isiness in later life. As there are many cliarlatan scliools advertising 
to give .such instruction, the phy.sician should first make diligent inquiry 
as to which are conducted upon scientific lines, and then recommend one 
of them to the ])arents of the patient. 

Lip reading may also be ])rofitably studied l)y adult deal' persons 
whose early education in lliis resj)ec-t was negleeled. 

5G 



i 



INDEX 



Abductor, paralysis, bilateral, 496, 498 
Abscess, brain, 763 

operation for, 824 
cerebellar, operation for, 824 
extradural, 757 

operation for, 830 
intradural, 761 
laryngeal, 737 
retropharyngeal, 341 
Accessor}^ sinuses, 163-239 

hyperemia of mucous membrane 
■ of, 18 
Acetozone inhalant, 59 
Actinomycosis of middle ear. 311 
of nose, 307 
of pharynx, 308 
of tonsils, 308 
Acute catarrhal laryngitis, 423 
in children, 429 
phlegmonous, 432 
otitis media, 670 

etiology of, 670 
pathology of, 676 
prognosis of, 680 
symptoms and diagno- 
sis of, 676, 677 
treatment of, 681 
pharyngitis, 334 
coryza or cold in head. 130 
infectious epiglottitis, 421 
inflammation of external attic of 

ear, 685 
labyrinthitis secondar}- to menin- 
gitis, 851 
lacunar lingual tonsillitis, 331 

lonsillilis, 377 
inastoidilis, 731 

indications of, 776 
jjcrioslitis of mastoid 7;!<i 
phlegmonous lingual tonsillil is, 331 
primary inflanunat ion of IIk; iai)V- 

rintli, 850 
rhinitis, 130 
sui>|,iir:iliv<> ..lilis nu'diii, TON 

in iiil';inls.'in(l cliiMivn, 
715, 716 
Adami, 106, 117, 127 
Adenoid expression, 322 

face, 318 
Adenoids, 315 

anatomical barriers to rcnioNal oi, 
324 



Adenoids and the blood, 329 
and bone dcA-elopment, 329 
changes in blood in, 329 

in chest walls in, 329 
chest walls in, 319 
clubfoot in, 329 
collateral symptoms of, 320 
diagnosis of, 321 
ear complications of, 322 
discharge in, 328, 334 
disturbance in, 328 
effect upon the voice, 505 
epipharyngeal inflammation in, 308 
ancl epiphar3'ngitis the chief cause of 

laryngitis stridulosa, 429 
etiology of, 315 
fever attending, 36 
gothic arch in, 327 
mental development in, 328 
operations of, 325 
pathology of, 315 
prognosis of, 322 
and the respiratory system, 328 
Thornwaldt's disease in, 330 
sequelae of, 226 
symptoms of, 318 
treatment of, 322 
Adenoma of nose, 264 
Adhesion of membrana tynipani to prom- 
ontory, 702 
of septal cartilage, 90 
surgical treatment of, 702 
Adhesions in acute otitis media, 682 
Adhesive processes in miildlc car, 692 
dingiK.sis i.r, (i'.Ki 
eliolim\ (if. (i'.»2 
pathology of, (;93 
symptoms of, 694 
treatment of, ()97, 702 



lllo 



Adit us ad antrum, 57 
Adrenalin chloride, 5'. 
After-treatment and o 

tic surgery of I'acinl nei-\i' 

of radical mastoid opeml ion 

of simj)le mastoid o|>er;ition 
Agglutination in removal of 

bodies from ear, 60() 
Air pressure, 44 

negati\e, 22 
Akinesis of larynx, 482 

or ])aralysis of pharynx, 347 
Al;e nasi, collapse of, 283 
Alcohol as a gargle, 55 

in suppurative otitis media, ; 



884 



INDEX 



Alcohol treatment of otitis media. 749 
Allen's nasal speculum, 97 
Allport. Frank, 806 
Allport's bone-crushing forceps, 811 
mastoid mallet, 781 
retractor 811 
Alternating nasal stenosis, 69, 137 
-Alveolar operation on antrum, 221 
Amnesic agraphia, 869 

aphasia, 869 
Amusia, 869 i 

Anastomosis of facial and hypoglossal 

ners-es, 841 
Anatomical landmarks of labyrinth, 816 ; 
mastoid, 779 I 

Anatomy, clinical, of the nose, 17 ■ 

of Eustachian tube. 569 
of external ear, 567 
of membrana tympani, 569 
of middle ear. 568 
and physiologj' of ear, the clinical, 

567 
of tonsil, clinical, 364, 389 
Andrews, A. H., 54, 120, 714, 715, 776 
Anemia cause of rhinitis with collapse 
of swell bodies, 31 
and collapse of swell bodies, 19 
of labyrinth, 846 j 

• result of chronic nasal infection, 31 | 
Anesthesia, cocaine, by injection, 21 _ 1 
in incision of membrana tjTupani, I 

648 
local, in tonsillectomy,. 393 
of mucous membrane, 32 
of phar>-nx, 346 

in tracheoscopy and bronchoscopy, 
552 
Aneur\sm, paresis of adductors from, 501 
Angina lacunaris of pharjmgeal tonsil, 313 
Angioma of auricle, 616 
of nose, 264 
of pharA-nx, 354 
of tonsil, 415 
Animate foreign bodies in ear, 605 
treatment of, 605 

by agglutination, 

606 
by chloroform, 606 
by drowning, 605 
instruments of 
little value, 606 
Ankylosis in hyperostosis of capsule of 
labyrinth, 705 
of stapes, 596 
Anosmia, 23, 240 
Anterior ethmoidal sinuses, 167 
Antiseptic and detergent solutions, 58 
Antitoxin in diphtheria, 463 
dosage, 463 
effects on pseudomembrane, 464 

on temperature, 464 
indications for, 464 
place of injection, 464 
Antriun of Highmore, 168 

Cald well-Luc operation on, 223 
cysts of, 183 



Antrum of Highmore, Denker's operation 
on, 224 
extranasal operation on, 221 
Kuster's operation on, 222 
Vail's operation on, 217 
mastoid, 48, 575 
opening of, 781 
transillumination of, 173 
Aphasia, sensory, word-deafness, 869 

simple mutism, 880 
Aphonia spastica, 483 
Apoplexy, larj-ngeal, 485 
Appendicitis and tonsils, 32 
Appendix vermiformis in relation to 

tonsils, 32 
Aprosexia in adenoids, 320, .328 
Aquiline or hump nose, 277 
Arch, gothic, 60 
Aristotle, 872 
Arnold, Jacob D., 422, 423 
Arsenic paste in lupus, 287 
Articular rheumatism. 32 
Arterial supply of nasal chambers, 24 
Arteries of middle ear, 576 

of tonsil, 371 
Asch, 71-81 
Asch's scissors, 82 

septmn forceps, 82 
Asch-Mej^er operation, 81 

after-treatment of, 83 
Asphyxia in diphtheria, causes of, 459 
Asthenopia, muscular, due to nasal 

disease, 38 
Asthma. 67, 252 
bronchial, 32 

Miller's, 429. See Acute laryngitis 
in children. 
Atkin.son, 415 
Atrophic larj-ngitis, 445 
rhinitis, 157 

etiology of, 157 

and suppurative sinuitis, 114, 1.58 

symptoms of, 160 

treatment of, 160 

paraffin injections in, 161, 
282 
Atrophy, pressure, 47 
Auditory nerve, paralysis of, 864 
hysterical, 865 
rheumatic, 865 
Auricle, absence of, 612 
angioma of, 616 
cysts of, 618 
dermatitis of, 623 
epithelioma of, 618 
fibroma of, 617 
frostbite of, 624 
herpes of, 622 

zoster of, 623 
keloid of, 618 
lupus of, 287 
malformations of, 611 
perichondritis of, 621 
sarcoma of, 620 
Auscultation during the tympanic infla- 
tion, 679 



INDEX 



Auscultation tube, 663 
Author's complete tonsil operations, 396. 
403 

ecraseur tonsillotome, 400 

tonsil syringe, 414 
Autophony, 688 



B 



Bacillus leprae, 304 

mallei in g^landers, 305 

of rhinoscleroma, 271 
Bacon, Gorham, 763-855 
Bacteriological diagnosis of diphtheria, 

452 
Bacteriology of acute otitis media, 670, 
707 

of diphtheria, 451 

of otitis media, 753-756 

of rhinoscleroma, 271 
Baginsky, 449 

Ball, James B., 332, 381, 387 
Ballance, Chas., 793, 794, 795, 796, 807. 

808, 812 
Ballenger, Wm. L., skiagraphs of the 

sinuses by, 186 
Ballenger-Foster forceps, 73, 93, 96 

septum speculum, 97 
Baratoux. 854 
Barbon, 732 

Bardeleben, Karl von, 837 
BarnhUl, F. J., 324 
Baron, 253 

Basilar membrane, 580 
Basin, hot-water, 41 
Batthng Nelson, 615 
Beard, F., 357 
Beck, J C, 47, 98, 149, 157, 161, 186, 288, 

295, 311, 842 
Beck's mercury-tube ear massage, 47 

paraffin syringe, 161, 280 
Benign neoplasms of pharynx, 350 

of tonsils, 415 
Benzoin, compound tincture of, 53 
Berard, 308 

Berens, T. Passmore, 574 
Bezold Fr., 856, 857, 858, 859 
liezold-Edlemann forks and whistles, 588 
Bezold's mastoiditis, incision in, 810 

operation for, 814 
Bickel, 313, 454 
Bier, F , 357 
Bier's treatment, 118, 126 

indications for, 128 
of mastoiditis, 735 
Bilateral abductor paralysis, 496 
King, (J98 
liing's test, 593 

Binnafont's mciliod of inflalion, 062 
Birkett, Herbert S., 1X5 
IMsmutli, subnitrate, 53 
Blackley, 244 

Blake, Clarence J., 587, 618, 706, 707, 857 
Bleyer, J. Mount, 507, 508 
IMindness. tone, 507 



Blood supply of anterior ethmoidal 
artery, 23 

a. nasalis posteriores septi, 24 

deficient in oxygen, 29 

in adenoid children, 329 

excess of carbon dioxide in, 29 

of nose, 23 

posterior ethmoidal artery, 23 

sphenopalatine branch of middle 
meningeal artery, 23 
Boeckmann's adenoid curette, 324 
BoUs in meatus, 624 

Bone conduction, loss of, in multiple 
sclerosis, 38 
dust, 730 

necrosis, carbolic acid in, 54 
Bones and adenoids, 329 
Boric acid powder treatment of otitis, 749 
Bosworth, F. E., 61, 75, 417, 525 
Bosworth's septmn operation, 75 
Bouche, 349 
Boucheron, 880 
Bougies, medicated, 699 
Bourguet, 817 

Bourguet's guide and protector, 817 
operation on labyrinth, 817, 818 
Boubland, 523 
Bracket, wall, for lamp, 43 
Brain abscess, 31, 762 

operation for, 824 

symptoms of, 763 
Brandegee's adenoid forceps, 322, 323 
Brauers, 530 

Brawley, Frank, 118. 127 
Breathing, inferior costal, 502 

methods of, 502 
Breathwav, the, 29 
Broca, 732 

Bronchi, foreign bodies in, 548 
Bronchitis, 19 

Bronchoscopj' and tracneoscopv, 551 
Brown, J. S., 618 
Brown, Price, 71, 85 
Bro^\Tie, Lennox, 289, 300, 332, 33(5, 347, 

351. 352, 354, 519 
Bouci.e, 349 
Bruhl-Politzer, 730 
Bruns, 352 

Bryant, Joseph D., 417 
Buck, A. H., 302, 692 
Bulb, jugular, resection of, 835 
Bul!;i rlliinoidalis, obstruction due In, 1 15 
Burckli.-inli, Morian, 632 
Bunicll, Cliiis., 600 
Buttie-Pvnclion inhaler, 667 



Cabinet treatment, tal)le for, 10 

Calculus of tonsil, 383 

Caldwell, 186 

Caldwcll-Luc operation on antrum, 223 

Caldwell's method of making skiagrapf 

of sinuses, 186 
(";il(inu'l in irout iind litliemia, 30 



886 



INDEX 



Campbell, J. T., :i.i7 
Canal, frontonasal, probing of. 195 
Cananus, 872 

Cancer, excision of external carotid 
artery in, 358 

trypsin treatment of, 356 
Cannula, frontal sinus, 175 

Krause's, 216 
Capsulitis labyrinthae, 703 
Carbolic acid in otitis media, 54, 715 
Carbon dioxide, 19 

and adenoids, 329 

elimination of, 29 
Carcinoma of nose, 266 

of pharynx, 355 

of tonsils. 417 
Carel. 321 
Carotid artery, excision of, in cancer of 

head, 358 
Cartilage, columnar, 64 

incision of, 91 

re-formation after removal, 98 

removal with swivel knife, 92 

septal, 54 
Cartilaginous deviations of septum, 63 
Catarrhal laryngitis, acute, 423 
in children, 429 

Jhlegmonous, 432 
ia, acute, 670 

etiology of, 670 
pathology of, 676 
prognosis of, 680 
svmptoms and diagno- 
■ sis of, 676, 677 
treatment of, 681 
pharyngitis, acute, 334 
Chaleway's spokeshave, 77 
Charsley, 253 
Chiari, 311, 444, 475 
Chromic acid in submucous cauterization 

of nasal membrane, 141 
Chronic rhinitis with turgescence, 137 
Chest walls in adenoids, 319 
Chloroform in screw-worms in ear, 601- 

606 
Cholesteatoma, 728 
Chorda tympani nerve, 573 
Chorditis nodosa, 444, 475 
Chorea, laryngeal, 483 
Chronic granulomata, 285 

hypertrophic laryngitis, 439 
lacunar tonsillitis, 381 
laryngitis, 438 
mastoiditis, 737 

indications of, 739 
prognosis of, 738 
symptoms of, 737 
treatment of, 739 
otitis media, moist catarrhal, 685 
etiology of, 686 
svmptoms of, 687 
treatment of, 690 
suppurative, 718 

acute exacerbations of, 

719 
pathology of, 718 



Chronic otitis media, suppurative prog- 
nosis of, 723 
symptoms of, 723 
treatment of, 723 
pharyngitis. 335 
rhinitis, 157 
Church, J. F., 600, 601 
Clerg3anen's sore throat, 335, 505 
Clinical anatomy of ear, 567 
of nose, 17 
of tonsil, 364 
significance of perforations of drum- 
head, 721 
Clubfoot and adenoids, 329 
Coakley, C. G., 165, 186 
Cocaine anesthesia in tonsillectomy, 396 
Cochlea, function of, 580 
hyperostosis of. 706 
Coffin; 166 

Cooper, Sir Astley, 701 
Cooper-Hewitt light in tuberculosis of 

larynx, 295 
Cooper's operation on antrum, 221 
Coghill, 290 

Cohen, J. Solis, 248, 290, 482 
Cohen, R., 511 
Cold in head, 130 
Collapse of alse nasi, 283 
Complications of acute suppurative otitis 
media, 710, 711 
of adenoids, 326 
of foreign bodies in trachea, 555 
and sequelae of acute lacunar ton- 
sillitis, 379 
of diphtheria, 460 
of quinsy, 385 
of tonsil operations, 411 
Conitzen, 351 

Contents of tympanic cavity, 572 
Continual hoarseness in cancer of larvnx, 

525 
Cooley's fluid in rhinoscleroma, 273 
Coolidge, Frederick, 329 
Corlin, 436 
Corti, cells of, 580 
organ of, 580 
Corwin's chisels for remo\'ing the naso- 

antral wall, 220-223 
Coryza, acute, 130 

edematosa, 250 
Cosolini, 416 
Cough, nervous, 485 
Counterirritation, 123 
Crile, 545 
Crisp, 422 
Croup, 433. See Membranous laryngitis. 

false or pseudo-, 429 
Croupous inflammation of meatus, 628 
treatment of, 628 
laryngitis, 433 
Cruveilhier, 354 

Cru\eilhier's submucous plexus, 354 
Crypts of tonsils, 365 
Cunes, 522 
Cupping, wet, 123 
Curettage in laryngeal tul)erculosis. 295 



INDEX 



887 



Curtis, Holbrook, 44, 445, 502, 504 
Cystoma of pharynx, 351 

of tonsils, 416 
Cysts of antriun and middle turbinated 
bone, 183 

of auricle, treatment of, 618 



Dabney, Wm. R., 127, 200 
Daly, William, 29 
Darwin's tubercle, 614 
Dawbarn, 358, 359, 530 
Dawson, 362 

De Vilbiss' spray tubes, 44 
Deaf-mutism, 872 

articulate speech in, 881 
causes of, immediate, 875 
classification, 873 
diagnosis of, 880 
etiology of, 873 
heredity, 874 
historical, 872 
lip reading in, 881 
pathology of, 876 
prognosis of, 880 
sign language in, 881 
speech in, 877 
symptoms of, 877 
treatment of, 880 
Deafness in chronic otitis media, 687 
due to intracranial tumors, 869 

to locomotor ataxia, 870 
leukemic, 854 

lip reading a compensation for, 881 
occupation, 861 
relief of, 45 
simulated, 862 
Defects of singing voice, 499 
of speech, 510-512 

due to deaf-mutism, 516 

of epipharyngeal and faucia) 

origin, 513 
of larj'ngeal origin, 514 
of lingual origin, 513 
of nasal origin, 512 
thoracic and abdominal, 514 
Deformities, surgical correction of exter- 
nal nasal, 277 
Dehio, 290 
Drlfvan, D. B., 415 

I )(lsi;inche, Chas., 44, 45, 46, 125, 684, 698 
Dcni.iic, 290 

l)<n<'li, l-:. V,.. 701, 729, 733, 760, SOS 
DcnkiT's (.per;. lion r.n anlniin, 221 
|)c|itvs, 302 

Dermatitis of auricle, 623 
I )eviations of septum, 72 
angular, 72 
cartilaginous, 71 
compound or S-sh;i|ici|, 72 
cup-shaped, 71 
osseous, 72 
Diiigiiosis of adenoids, 321 
of •■iftinomvcosis, 309 



Diagnosis of acute pharyngeal lacunar 
tonsillitis, 314 
of adhesive otitis media, 696 
of cancer of larynx, 529 
of catarrhal pharyngitis, 334 
of chronic laryngitis, 441-447 
differential, of sinuitis, 171 
of diphtheria, bacteriological, 452 
of fibroma of pharynx, 353 
of foreign bodies in trachea, 548 
of laryngeal tuberculosis, 293 
of membranous laryngitis, 435 
of orthematoma, 615 
of retropharyngeal abscess, 341 
of rhinoscleroma, 273 
of sinus disease, 172 
of tuberculosis of larj^nx, 293 

of mastoid process, 296 

of middle ear, 296 

of pharynx and fauces, 289 
Diagnostic and therapeutic value of 
■ catheterization, 664 
tube, 663 
Diaphragm, the, in respiration, 18 
Dieulafoy, 361 

Diffused inflammation of meatus, 626 
Dilatation of the Eustachian tube, 699 
Diphtheria, 462 

antitoxin in, 462 
aural, 459 
bacteriology of, 451 
bronchopneumonia in, 461 
cardiac or vagus paralysis in, 461 
causes of asphyxia in, 459 
complications and sequelae of, 460 

bronchopneumonia, 461 

cardiac or vagus paralysis, 461 

gastro-intestinal, 460 

heart lesions, 460 

hyperleukocytosis in, 460 

nervous, 460 

postdiphtheritic paralysis, 460 

skin, 461 

urinary, 460 
diagnosis of, 459 
etiology of, 459 
gavage in, 474 
histopathology of, 453 
intubation in, 468 

complications of, 471 

feeding after, 472 

indications for, 4()S 

removal of tube, 46!t 

technique of, 4()S 

when to rcuioNc I ulic. 171 
liuyngcui, 157 

septic or mixcil iiilcclioii in, I.IS 

.stage of invasion, 45S 
of asphyxia, 458 
of spasm, 45S 
modes of infcclion in. 150 
opiTilion lor, 105 

traciicotoniy, J(15 
prognosis ol', 159 
propliyiaxisof, Kil 
.symptoms of, 155 



f^S8 



INDEX 



Diphtheria, tracheal, 459 
treatment of, 459-462 
types of, 455 
Diphtheritic inflammation of meatus, 631 
laryngitis, 433 

or peripheral paralysis of pharynx, 
348 
Diplakousis, 581 
Direct laryngoscopy, 557 
anesthesia in. 557 
posture of patient in, 557 
through the tube spatula, 360 
Distortions of auricle, 612 
Dizziness in sinuitis. 166 
Doutrelpont, 286 
Drainage, 342 

obstruction to, 48 
Dressing, mastoid, 786 

Pischel's collodion, 76 
Drowning animate foreign bodies in ear, 

606 
Dry gauze treatment, 748 
Duchemin, N., 507, 508 
Duel, A. B., 599, 657, 707. 708, 709 
Dunbar, 249 
Dunbar's serum treatment of hay fe\er, 

249 
Duplay, 732, 733 
Dupuy, 648 



Ear, actinomycosis of, 311 

complications and adenoids, 322 
diseases and adenoids, 328 
foreign bodies in, 600 
middle, and Eustachian tube, 651 
neoplasms of external, 614 
pneumomassage of, 44 
syphilis of external, 302 
Ecraseur tonsillotome, author's, 400 
Eczema of external ear, acute, 634 

chronic, 634 
Edema of larj^nx, 436 
chronic, 478 
circumscribed, 436 
etiology of, 436 
pathology of, 437 
prognosis of, 437 
surgical treatment of, 437 
symptoms of, 437 
of nose, acute circumscribed, 520 
of uvula, 337 
white, 127 
Edinger, 488 
Eisendrath, D N., 369 
E^isenlohr, 489 
Electric cautery, 45-47 

in rhinitis with turgescence, 140 
Electrolysis in angioma of pharynx, 354 

of Eustachian tube, 657 
Elevation of mucoperichondrium, S9 
Elongated uvula, 337, 338 
treatment of, 339 
Empyema of sinuses. 171 



' Endolaryngeal operation on cancer of 
I larvnx, 532 
Enddlymph, 580 
Englemann, 190 
Epiglottitis, 421 

malarial, 423 
Epilepsy of nasal origin, 253 
Epipharyngeal inflammation and ade- 
noids, 328 
space in relation to adenoids, 324 
Epipharynx, crusts in, a sign of sinus 
disease, 176 
i Epistaxis, etiology of, 139, 269 
treatment of, 270 
Epithelial plugs in the meatus, 609 
Epithelioma of auricle, 618 

treatment of, 620 
Epithelium, characteristics of, in ade- 
noids, 316 
lowered in vitality, 18 
of tonsil crypts, 366 
Equilibrium, disturbances of, in sinuitis, 

189 
Erectile tissue, rhinitis with collapse of, 

156 
Erhard's test for simulated deafness, 863 
Escat, 333 

Escat's position of head, 174 
Esmarch, 262, 342 
Esophagoscopy, 564 
technique of, 565 
upper, 564 
Ethmoid, deviations of perpendicular 
plate of, 73 
operation through orbit, 237 
Ethmoidal cells and middle turbinal 
removed en masse, 232 
exenteration via the intranasal 

route, 228 
partial removal of, 222 
empyema, thrombosis of longitudinal 

and cavernous sinuses in, 184 
sinuses, anterior, 167 
posterior, 170 
surgerj^ of, external, 236 
suppuration with external perfor- 
ating, 167 
Ethmoiditis and sphenoiditis, causes of 

otitis media, 690 
Etiology of abscess of larynx, 437 
of actinomycosis of nose, 307 
of acute laryngitis, 424 

lacunar tonsillitis, 377 
otitis media, 670 
phlegmonous laryngitis, 432 
suppurative otitis media, 707, 
708 
of adenoids, 315 
of adhesive otitis media, 692 
of atrophic laryngitis, 445 

rhinitis, 157 
of cerebrospinal hydrorrhea, 251 
of cerumen in meatus, 608 
of chronic lacunar tonsillitis, 381 
laryngitis, 439 
pharyngitis, 335 



INDEX 



889 



Etiology of chronic rhinitis with turges- 
cence, 137 
of defective hearing, 594 
of defects of singing voice, 499 
of diffused infianimation of meatus, 

326 
of edema of larj^nx, 436 
of epistaxis, 269 
of exostosis of meatus, 628 
of facial paralysis, 839 
of fibroma of pharynx, 352 
of furunculosis of meatus, 624 
of glanders, 305 
of iiay fever, 241 
of hyperkinesis or spasm of pharvnx, 

349 
of hvperostosis of bony capsule of 

labyrinth, 703 
of Ityperplastic rhinitis, 150 
of inflammatory diseases of nose and 
accessory sinuses, 105 
of throat and ear, 48 
of intranasal causes of sinuitis, the 

author's ideas of, 201 
of laryngeal cancer, 525 
of leprosy, 303 

of membranous larjmgitis, 434 
of nasal actinomycosis, 307 

polypus, 254 
of neoplasms of larynx, 518 
of othematoma, 614 
of perforation of the niembrana 
tj^mpani, 641 
of septum, 100 
of quinsy, 383 

of retropharyngeal abscess, 341 
of rhinitis with collapse of erectile 
tissue, 156 
with hyperplasia of tissue, 150 
with Itypertrophy of tissue, 142 
of rhinoscleroma, 271 
of sinus diseases, 179, 180 
of spongifying, 703 
of tuberculosis of larynx, 290 
Eustacliian bougies as foreign bodies in 
Eustachian tube, 607 
tube, catarrhal inflammation of, 652 
curettage of, in radical mastoid 

operation, 762 
electrolysis of the, 657 
foreign bodies in, 607 
massage of, 668 
obstruction of, 655 

in middle-ear diseases, 651 
physiology of, 578 
in relation to mastoiditis, 655 
in spongifying of the labyrinth, 
705 
Evans, Mr., 507 
Examination lamp, 43 
Excision of external carotid artery, 358 
in inoperable cancer of 
head, 35S 
Exenteration of semicircular canals, S17 
Exostosis of meatus, 628 
Expiratory current of air, 17 



Extradural abscess, 759 

operation for, 830 
Eye in relation to the sinuses, 166 

symptoms in sphenoiditis, 171-184 



F 



Facial and hypoglossal nerves, plastic 
surgery of, 839, 841 
nerve, 574 

paralysis complicating pharyngeal 
paralysis, 349 
due to intracranial tumors, 869 
etiology of, 839-841 
plastic surgery of, 480 
in surgery of labyrinth, 824 
False croup, 429 
Farlow, John W., 354, 415 
Farlow's tonsil punch, 410 
Fauces and pharynx, pillars of, 368 
syphilis of, 299 
tuberculosis of, 289 
and tonsils, diseases of, 360 
Fenestra coclilea, 574 

vestibuli, 574 
Fenger, Christian, 828 
Ferreri, 520 

, Fetid otorrhea, significance of, 255 
' Fetterolf's file saw, 84 
Fibro-enchondroma of tonsils, 416 
Fibroma of auricle, 617 
nasal, 261 
of pharynx, 352 
of tonsils, 415 
Finsen light in laryngeal tuberculosis, 295 
in lupus, 287 

in nasal tuberculosis, 289 
photography, 287 
Fish, H. M., 166, 184, 190, 191 
Fistula in auris congenita, 612 

postauricular, plastic surgery of. 836- 
838 
Flap, tongue, Gleason's, 80 
Flatau, 415 
Forceps, Asch's septum, 82 

Brandegee's forward cutting, 220 
Foster-Ballenger, 93-96 
McAuliff's adenoid, 322 
Roe's, 81 

Smithuison's sphenoid, 238 
Foreign bodies in ear, 600 

treatment of, 601-605 
meddlesome, 602 
in Eustachian tube, 606 
in larynx, trachea, l)ronchi, and 
esophagus, 
548 
complications 

of, 555 
general con- 
siderations 
of, 555 
rein()\-al nf, 
551 
ill nnsc, IS. L>'.).-, 



890 



INDEX 



Foreign bodies in nose, causeolsinuitis, ISO 

character of, 555 
Formaldehyde in tuberculosis ol' the 

larynx, 294 
Foster, Hal, 274 
Foucher, 333 
Frontal sinus, 163 

cannula, 175 

operation of Hajek-Luc, 210 
skiagraphs of, 163 
1^'rontonasal canal, probing the, 195 
Fraenkel, B., 253, 290, 528, 532 
Frazier, 765, 766 
Fredet, 422 
Freer, Otto, 86, 98 
Freer's incision, 88 
Freudenthal, 273, 295 
Friedlander's bacillus, 271 
Friedreich, E. P., 29, 360 
Frog-face in fibroma of pharynx, 352 
Frostbite of auricle, 624 
Funke, John, 753 
Function of cochlea, 580 

of semicircular canals, 580 
of vestibular apparatus, 580 
Functional neuroses of pharynx, 346 
anesthesia, 346 
hyperesthesia, 346 
paresthesia, 346 
range of nearing, 587 
tests in acute otitis media, 678 
of hearing, 585 

acoumeter, 587 
Bing test, 593 
Gelle test, 593 
Schwabach test, 591 
in spongifying of body cap- 
sule of labyrinth, 705 
voice test, 386 
watch test, 586 
Weber experiment, 589 
Furguson-Pynchon mouth gag, 323 
Furunculosis of meatus, 624 
of nose, 273 



Gallaher, Thomas, 294 

Galton whistle, 589 

Gangrene in glanders, 306 

Gases, interchange of, in ^-esicles of 

lungs, 29 
Gautier, 310 

Gavage in diphtheria, 474 
Gelle test, 593 
Gellius, 872 
Gerhardt, 518, 526 
Gibb, 422 
Gigli saw, 835 
Glanders, etiology and pathology of, 

305 
Glass, 273 

Gleason, Edward B., 71 
Gleason's operation, 79 
Gleitsmann, Joseph W., 290, 295 



Gluck, 429 

Goldstein, M. A., 103, 142, 274, 275, 298, 
698, 858 

Goldstein's plastic operation for perfora- 
tion of septum, 103 

Goodale, Joseph L., 48, 272, 290, 360, 361, 
367, 377 

Goodsir, 316 

Gothic arch in adenoids, 327 
of palate, 327 

Gottstein, 488, 628, 851 

Gradinego, 585, 724, 855, 869 

Gradle, H., 724, 754, 755, 758 

Grafts, Thiersch, 807 

Grant, Dundas, 701 

Granular pharyngitis, 335 

Granulomata, chronic, of nose, throat, 
and ear, 285 

Green, 522 

Grober, J., 365, 370, 371, 372 

Gruber, 253, 640, 851 

Grunert, 769 

Grunwald, 157, 184 

Grunwald's forceps, 153, 154 

Guinea-pig inoculations a test for tuber- 
culosis, 288 

Gidland, G. L., 365 

Guns, 157 

Gustatorv function of the nose, 17 

Guye, 284, 320, 849 

Guyon, 354 

Guyot, 354-662 



Habermann, 728, 877 
Hack, 253 

Hair cells of the organ of corti, 581 
Hairy polypi of the pharynx, 351 
Hajek, 421, 444 
Hajek-Luc operation, 210 
Hajek's elevators, 89 
hand burrs, 805 
incision, 88 
Halle, Max, 207 

Halle's frontal sinus operation, 207 
Halstead, 548 
Hansen, 304 
Harpy, 294 
Hartley, Frank, 530 
Hartmann, A., 589, 857, 872, 878, 880 
Hartmann's forks, 589 
Hartz, Henry J., 707 
Hay fever, etiology of, 241 

pathology of, 244 

prognosis of, 245 

sinus disease as a cause of, 243 

symptoms of, 244 

treatment of, 246 
Hazletine, Burton, 104 
Hazletine's plastic operation for perfora- 
tion of septum, 104 
Head, G. P., 741 

Headache due to irritation of trigeminus, 
38 



INDEX 



891 



Headache, A-ertexial and occipital, a sign 

of sinuitis, 176 
Hearing, functional tests of, 583 

range of, 587 

of voices and music, 868 
Heath, C, 48, 723, 786, 804 
Heinze, 291 
Heitzmann, 393 
Helmholtz, 580, 581, 849 
Hemorrhage, labyrinthine, 847 

nasal, 269 

tonsillar, after operation, 374, 411 

turbinal, after operation, 156 
Hemorrhagic inflammation of the meatus, 
627 

laryngitis, 447 
Henle, spine of, 779 
Heredit}^ and deaf-mutism, 774 

in spongification or hyperostosis, 706 
Herodotus, 872 
Herpes of auricle, 622 

zoster of auricle, 623 
Hibbard, 454 
Hillis, 474 
Hillis' method of feeding intubated 

infants, 474 
Hilus of the tonsil, 366 
Himly, 701 
Hippocrates, 872 
His, 365 

Histopathology of diphtheria, 453 
Hodgkin's disease in malignant neo- 
plasms, 357 
Hollander, 287 
Hollinger, J., 732 
Holmes, C R., 598, 732, 733 
Holmes' middle turbinal scissors, 154 
Hopkins, E. F., 393 
Hopmann, 253 
Horslev, 488-492 
Hotz, F C, 745 
Hotz's aural applicator, 812 
Hovell, T. Mark, 643, 682, 851, 857. 858 
Hunt, 286 

Hurd's septum forceps, 89 
Hydrorrhea, nasal, 240, 250 
Hyperacuteness of hearing, 251 
Hyperemia of labyrinth, 846 

of nose and accessory sinuses, 18 
Hyperesthesia acoustica, 866 

of pharynx, 346 
Hyperesthetic rhinitis, 241 
Ilypf^rkeratosis of the tonsil, 387 
llv|KTkinesis or spasm of pharvnx, 347- 

";;i9 

lIy|)irosmia, 240 

Ih piTostosis of bony fiipsulc of lal)V 

rinth, 694, 703 
Hyperplasia of bony capsule ol l;il)\riiit li, 
703 
of mucous membrane, 18, 150-152 
Ilyp('r])l;isl i(; and papillary growtlis of 
larynx, 47S 
rhinitis, 18, 150, 152 
Hyporsonsitiye rhinitis, 211 
Hypcrseiisitivciiess of ])liaryn\, ;5l(i 



Hypertrophic rhinitis, 18, 142 
Hypertrophy of lingual tonsil, 332 

of mucous membrane, 18 

of tonsil, 386 
Hj^posmia, 240 

Hysterical paralysis of auditory nerve, 
865 



Ibsen, 877 

Ice in acute otitis media, 715 
Incision in brain abscess, 825 
Freer's, 88 
Gleason's, 80 
Hajek's, 88 
indications for, 645 
Killian's, 88-90 
mastoid, in infants, 810-813 
of membrana tympani, 642, 715 
Index, opsonic, 127 

Indications, early, of malignant neoplasms 
of the larynx, 525 
for Bier's treatment, 128 
for incision of membrana tympani, 

645 
for operation in acute mastoiditis, 

776 
for radical mastoid operation, 739 
for removal of foreign bodies in 
larjmx, trachea, and bronchi, 
549 
of tonsils, 393 
for septum operations, 17 
Infection, conditions favorable to, 18 
following tonsil operations, 411 
of limgs at apex, 371 
modes of, in leprosy, 304 
source of, in laryngeal tuberculosis, 

291 
tonsils as portals of, 360 
Infectious diseases, opsonic index and 
vaccine treatment of, 128 
fevers in relation to acute suppura- 
tive otitis media, 707 
Inferior costal breathing, 502 
Inflammation, acute, 105 
causes of, 108 

of external attic of oar, S50 
reactions of, 105 
ciironic, causes of, 108 
reaction of, 107 

modalities for pronioling. 

117, 122 
quality of, 106 
suppuratiye, cause ol', IS 
t rcatment of, principles of, 1 17. ILM 
Iiidiiniinatory disca.ses of nos(' and acces- 
sory sinu.ses, 105-130 
of tonsil.s, 376 
lii(l:i(i(in. comparalivc value of luelluHls 
(pI, (iCiS 
of middle ear, (iOl 

|)riiiciples of, (i.")'.t 
ill (.litis media, aelile, (ISJ 
clirouic, 691 



892 



INDEX 



Inflation with nebulizer, 665 

Influenza, nipple perforations of uiem- 

brana tvmpani in, 712 
Ingals, E/F., 415, 551 
Injuries of niembrana tj-mpani, 637 

of labyrinth, 860 
Inspirator}- current of air, 17 
Intracranial complications of sinuitis, 166 

and jugular pyogenic diseases of otitic 
origin, 757 
Intradural abscess, 761 
Intubation in bilateral adductor paraly- 
sis, 498 

in diphtheria, 468 
Iodide of potash in spongification (hyper- 
ostosis), 706 
Irrigation in acute otitis media, 741, 747 

of lavage, 124 

of sinuses, 195, 196, 197, 198, 199 
Itard, 873 



Jack, Frederick L., 706, 707 

Jackson, Chevalier, 44, 489, 527, 529, 549, 

550, 553, 558, 565 
Jacobson, 591 
Jansen, 226, 227 
Jansen's mastoid retractor, 811, 812 

mouse tumor, 357 

operation on the sinuses, 226 
Johnson, 294 
Jugular bulb, thrombosis of, 833 



Kahn, Harry, 264, 587 

Kalisko, 454 

Katz, 705 

Kaufmann, 373, 382, 387 

Keen, W W., 542 

Keimer, 415 

Keloid of the auricle, 618' 

Keratosis obturans, 609 

Key to sinus diseases, 701 

Kierstein's head lamp, 43 

Killian, Gustav, 73, 165, 186, 213, 214, 
215, 366, 549, 550, 552, 555, 556, 557 

Killian's incision, 88, 90, 237 
frontal sinus operation, 213 
septum knife or spokeshave, 98 

Hebs, 451 

Klebs-Loeffler bacillus, 380, 451 

Knapp, H., 760, 875 

Knife swivel, the author's, 92, 94 
mucosa, 218 

Knight, Chas. H., 290, 291 

Knives, the author's middle turbinal, 231 

Knoblauch, 870 

Koch's new tuberculin, 299 
opsonic index, 299 

Kocher, 362, 529 

Koerner, 765, 786 

Kowalizig, E., 262, 342 

Kramer's method of inflation, 662 



Kraus, 488, 492 

Krause-Heryng laryngeal forceps, 520 

Krause's cannula, 216 

nasal snare, 153, 154 
Kronlein's landmarks of the skull, 827 
Kuhnt's operation on the frontal sinus, 

211 
Kuster's operation on the antrum, 222 
Kvle, D. Braden, 72, 158, 255, 264, 288, 

'309, 393 
Kyle's malleable nasal tubes, 85 

septum operation, 84 



Labyrinth, 712, 850, 851 

Bourguet's operation on the, 817 

facial paralysis in surger}- of, 824 

hemorrhage in, 847 

hyperemia of, 846 

hyperostosis of, 703 

injuries of, 860 

modiolus of, 820 

necrosis and suppuration of, 815 

neoplasms of, 871 

syphilis of, 854 
Lack, Lambert, 283, 284 
Lack's operation for collapse of alae nasi, 

283 
Lactic acid in tuberculosis of larynx, 295 
Lacunar pharyngitis, 335 

tonsillitis, acute, 377 
chronic, 381 
pharyngeal, 377 
Lake, Richard, 850 
Lamp bracket, 43 
Lamps, examination, 43 
Lancereaux, 290 
Landmarks, anatomical, of labj^inth, 816 

of mastoid process, 779 

of temporal bone, 567 
Landois, 588 
Langenbeck, von, 262 
Langenbeck's method of removing malig- 
nant tonsil, 418 

operation, 262 
Laryngeal apoplexy, 485 

chorea, 483 

diphtheria, 457 

tuberculosis, diagnosis of, 293 
in pregnant women, 296 
Laryngectomy, complete, 539 

partial, 538 
Laryngismus stridulus, 483 
Laryngocele, 476 
Laryngofissure, 533 

in bilateral paralysis, 498 

in syphilis of the larynx, 302 
Laryngoscopy in cancer of larynx, 533 
Laryngitis, acute catarrhal, 423 
in children, 429 

atrophic, 446 

chronic hypertrophic, 439 

hemorrhagic, 447 

membranous, 433 



INDEX 



893 



Laryngitis, phlegmonous, 432 
stridulosa, 429 

tuberculous, in pregnant women, 296 
Larynx, abscess of, 437 

cancer of, recurrence of, 547 
edema of, 436, 478 
foreign bodies in, 548 
h5^perplastic and papillar}^ gro-ni;hs 

of, 478 
lupus of, 286, 479 
malformations of, 476 

acquired, 476 
neoplasms of, 518 
neuralgia of, 284 
neuroses of, 482 

paralysis of intrinsic muscles of, 486 
rectal alimentation after operation 

on, 546 
shock in irritation of, 545 
stenosis of, 477-480 
leprous, 479 
traumatic, 479 
tuberculous, 479 
syphilis of, 301 
tuberculosis of, 290 
webs of, 478 
Latent form of chronic suppurative 

otitis media, 718 
Lateral sinus thrombosis, 767 

early diagnosis of, 768 
operation for, 831 
three stages, 767 
Laurentius, 872 
Lavage of sinuses, 124, 195, 196, 197, 198, 

199 
Lavele prize, 45 

Leeches in acute otitis media, 683, 716 
artificial and natural, 123 
in mastoiditis, 742 
Leiter's coil in perichondritis of auricle, 

621 
Lemcke, 872 

Lepra anesthetica seu nervosa, 304 
Leprosy, 303 

Leptomeningitis diffusa purulenta, 761 
Lermoyez, 321 
Leukemic deafness, 854 
Leukodescent light, 125 

in acute rhinitis, 136 
in lupus, 287 
in sinuitis, 103 
in tuberculosis of lar>nx, 295 
of nose, 289 
Leutert, 719, 720 
Levy, Robert, 256, 294, 297 
Lewin, G., 332 
Lichtwitz, 190 
Liebreich, 249 
Light, leukodescent, 125 
Lingual tonsil, 331 

catarrhal inflammation of, 331 
hypertrophy of, 332 
varix, 332 
Lip reading for dcaf-iiiutos, 881 
l^ipoma of nose, 2()() 
of pharynx, 353 



Lipoma of tonsil, 415 

Local anesthesia in tonsil operations, 396 

Lockard, Lorenzo B., 294 

Locomotor ataxia deafness, 870 

Loeb, H. W., 164, 249, 256 

Loeb's projections of the sinuses, 164 

Loeffler, 451 

Longitudinal sinus, thrombosis of, in eth- 

moiditis, 184 
Lop ear, 611 
Louis, 422 

Lowenberg, 296, 603 

Lowenberg's method of tj^mpanic infla- 
tion, 663 
Lubert, 732 

Luc-Hajek operation, 209 
Lucae's spring probe, 698 
Lumbar puncture, 758 
Lungs, air vesicles of, 329 

infection at apices of, 371 
Lupus of auricle, 287 

Beck's hot-air apparatus in treat- 
ment of, 287 

Finsen ray treatment of, 287 

of nose, 285 

of pharynx and larynx, 286 

Rontgen ray treatment of, 287 
Lymphadenoma, Hodgkin's disease, 417 

of pharynx, 351 
Lymphatic drainage of larynx, 522 
Lymphatics of tonsil, 369 
Lymphoma of nose, 264 

of pharynx, 301 
Lymphosarcoma of pharynx, 356 



M 



McAuliff's adenoid forceps, 322, 616 
McBride, 315, 316, 319, 320 
McKernon, J. F., 762, 763 
McKernon's rongeur forceps, 811 
Macdonald, Greville, 352 
Macewen, 732, 733, 736, 737, 738, 754, 

755, 758, 763, 767, 772, 829 
MacKenzie, E., 490 
MacKenzie, John, E., 299 
MacKenzie, Sir Morrell, 38, 393, 504. 505, 

519, 601 
Macrotia, 612 
Makuen, G. Hudson, 510, 514, 515, 

882 
Malarial epiglottitis and laryngitis, 423 
Malformations, acquired, 476 
of auricle, 611 

classification of, 612 

entire absence of, 612 
macrotia, 612 
microtia, 612 
distortions, 612 
congenital fistula, 012 
surgical treatment, 613 
of larynx, 470 
of mcmbrana tympani, 637 
of pliarynx, 344 
Mallierbe, Aristide, 702 



894 



INDEX 



Malignant neoplasms of auricle, 618 
of larynx, 522 

surgical treatment, 532 
of pharynx, 354 
recurrence of nasal, 206 
of tonsils, 417, 418 
trypsin treatment of, 350 
Mallein as a diagnostic agent in glanders, 

300 
Malleus and incus, removal of, 789 
Manicatide, 454 
Manual massage, 125 
Martin, 455 
Maschziker, 012 

Massage in ailhesive otitis media, 098 
apparatus. 44 
Beck's mercury tube, 47 
of Eustachian tube, 058-008 
manual mechanical pneumo-, 125 
in spongification, 700 
Massei, 481 

Mastoid antrum, 48, 575 
cells, 575 

chisels and gouges, 814 
cortex, the removal of, 783 
dressing, 785 

incision in infants, 810-813 
operation in infants and children, 
814 
meatomastoid, 802 
radical, 780 
simple, 877 
process, tuberculosis of, 290 
Mastoiditis, Bezold's surgery of, 814 
complications of, 712 
Eustachian tube in relation to, 055 
. sequelte of acute otitis media, 711 
treatment of, 120 

surgical, 780, 787, 802 
tvpes of, 735 
Matas, 250 
Maxillary sinus, 108 

author's operation on, 219 
Caldwell-Luc operation on, 223 
Cooper's operation on, 221 
Denker's operation on, 224 
Jansen's operation on, 220 
Kuster's operation on, 222 
Rethi's removal of naso-antral 

wall, 210 
surgery of, 215 
Avail's operation on, 217 
Maxwell, George Troup, 395 
Mayer, Emil, 190, 273, 000 
Mayer's nasal tubes, 78, 82, 83 
Mayo, Charles, 291 
Meatal retractor, 804 
Meatomastoid operation, 723, 788, 802 
Meatus, acute eczema of, 033 
boils in, 024 

bulging or sagging of, 731 
chronic eczema of, 034 
croupous inflammation of, 028 
diffused inflammation of, 620 
exostosis of, 028 
furunculosis of, 024 



Meatus, hemorrhagic inflannnation of, 027 
keratosis obturans of, 609 
mvcosis of; 632 
stricture of, 630 
wax in, 607 
Meatuses of nose, 18 
Mechanical massage, 125, 608 
Medicated bougies, 099 
Meissner, 157, 872 

Membrana flaccida in acute otitis media, 
710 
t3'mpani in acute suppurative otitis 
media, 710 
anesthesia of, 048 
incision of, 042 
inflammation of, 638 
injuries of, 637 
i malformations of, 637 

method of, 649-773 
paracentesis of, 645 
perforation of, 040 
physiology of, 577 
in spongification of the lab\'- 
rinth, 705 
Membranous laryngitis, 433 
Meniere's disease, 848 

tinnitus in, 807 
symptom complex, 849 

in hyperostosis of bony 
capsule, 704 
Meningitis serosa, 758 

acute labyrinthitis complica- 
ting, 851 
operation for, 830 
Mental development and adenoids, 328 
Mercury^ tube. Beck's massage, 47 
Metabolism or chemistry of nutrition, 19 
Metaplasia of labj-rinth, 703 
Metchnikoff , 307 
Methods of breathing, 499, 502 
Meyer, Wilhelm, 29, 320 
Mej-er's ring curette, 323 
Meyjer, 422^ 

Miasmatic epiglottitis, 423 
Michel, 421, 877 
Michel's metal suture clamps and clip 

forceps, 813 
Microtia, 012 

Middle ear, inflation of, 661 
tuberculosis of, 296 
turbinated body, cysts of, 183 
obstruction due to, 115 
Miller, 445 
Miller's asthma, 429 
Milligan, A. W., 290, 297 
Minot, 012, 000 
Modalities for promoting the reaction of 

inflammation, 117, 122 
Modiolus of the labyrinth, 820 
Mogiphonia, 485 
Mojocchi, 311 
Moil, 475 
Montain, 877 
Monte, 455 

Moos, 755, 852, 854, 875, 877 
Morbid material, 743 



INDEX 



895 



Morgagni, prolapse of the ventricle of, 477 

Morriss}^, 454 

Mosetig-Moorhof operation for fistula, 838 

Moss, Robert E., 396 

Most, 522 

Moure, E. J., 236, 324, 521 

Moure's operations, 85, 236 

Mouth gag, Furguson-Pynchon, 323 

Mucoperichondrium, elevation of, 89 

Mucopurulent rhinitis, 157 

Mucous discharge in catarrhal inflanima- 

tion of sinuses, 166 
MiJller, J., 728 
Mutism, 878 
Mycosis of meatus, 632 

of nose, 254 

of tonsil, 387 

leptothricia, 387 
Mygind, Holger, 286, 872, 873, 875, 877, 

880 
Myles, Robert C, 406 
Myles' barbed cannulas, 223 

reversed sinus chisels, 219-239 

sphenoidal chisels, 238 
Myringitis, 638 

Mj-xoma of the pharynx, 352 
Myxosarcoma of pharj^nx, 356 



N 



Nasal, actinomycosis, 307 

adenoma, 264 

angioma, 264 

carcinoma, 266 

chambers, chief resonators of voice, 
506 

deformities, external, correction of, 
277 

diseases and singing voice, 500 

douche cause of otitis media, 70S 

dressings cause of sinuitis, 180 

epilepsy, 253 

fibroma, 261 

furunculosis, 273 

hemorrhage, 269 

hydrorrhea, 240, 250 

lipoma, 266 

Ij'mphoma, 264 

neuroses, 240 

osteoma, 265 

papilloma, 261 

polypus, 254 

sarcoma, 267 

suppuration, 162 

tachycardia, 253 
Naso-antral wall, rcnio\al of, 216 
Necrosis and suppuration of labyrinth, 

816 
Negative air pressure, treatment by, 199 
Neisser's stain, 451 

Neoplasms, deafness due in inl i:icr;iiii;d, 
869 

of extcriiul car, 61 1 
malignant, 266 

of labvrinth, 871 



Neoplasms of larynx, 518, 522 

of nose, benign, 254 

of pharynx, benign, 350 

of tonsils, 251 
Nerve, auditory, 580 
Nervous cough, 485 
Neumann, 856 
Neuralgia of larj^nx, 484 

of pharynx, 347 
Neuroses, auditory, 866 

of larynx, 482 

paralysis, or akinesis, 482 
spasms, or hyperkinesis, 482 

nasal, 240 

of olfaction, 240 

of pharynx, 346, 347 

akinesis, or paralysis, 347 
hyperkinesis, or spasm, 347 

sensory, vasomotor, and reflex, 241 
Newkirk, 327 
Nipple perforation of membrana tympani, 

710, 712 
Nodules, singer's, 444 
Northrup, 451, 454, 455, 458, 465 
Nose, actinomycosis of, 307 

aquiline, author's operation for, 277 

chronic granuloma of, 285 

foreign bodies in, 275 

inflammatory diseases of, 130 

long or drooping contour of, 229 

lupus of, 285 

neoplasms of, 254 

screw-worms in, 224 

syphilis of, 299 

tuberculosis of, Finsen light in, 287, 
289 



O'DwYER, 468 

Obstruction of anterior portion of nose, 
112 

of drainage, 48 

due to bulla ethmoidalis, 115 
to uncinate cells, 118 

of Eustachian tube, 655 

of inferior meatus. 111 

of olfactory fissure, 113, 114, 115 

results of high, 114 

of vestibule, 18 
Obstructive deformities of septum, 17 
Occupation deafness, SlU 
Ochsner, A. J., 614 
Ocular symptoms in sinuitis, 110, 171 
Ogston-lAic operation, 209 
Olfaction, neuroses of, 240 
Olfactorv fissure. IS 

'ohstnictinn (.1, II i 
Ollicr's nasal ()|>cral inn. L'dS 
Ouodi. 227 
Operating chair, 10 
Operation for ai),^ccss ol luain, S24 
of larvnx. I3.S 

for adenoids, 323 

lor adhesive otitis media, 701 



896 



INDEX 



Operation for anastomosis of facial and 
hypoglossal nerves, 839, 841 
Asch-Mej-er, 81 

author's, for antrum disease, 219 
for ethmoiditis, 232 
for long or drooping nose, 279 
method in maxillary sinuitis, 219 
in Thornwaldt's disease, 331 
of turbinectomy, 232 
submucous, for deviation of the 

septum, 86 
tonsillectomy, 396-403 
Bezold's mastoiditis, 814 
in bilateral abductor paralysis, 498 
Bosworth's septum, 75 
Bourguet's labyrinth, 817-818 
Brown, Price-, septum, 85 
Caldwell-Luc, 223 
Casselberrv's, for elongated u\ala, 

340 
for cerebellar abscess, 824 
cochlea, 821, 823 
Cooper's, on antrum, 221 
Denker's, on antrum, 224 
for elongated uvula, Casselberrv's, 

340 
for excision of external carotid 

artery in cancer, 358 
external, on ethmoidal sinuses, 236 
on frontal sinus, 209 
nasal deformities, 277 
extradural, abscess, 830 
extranasal, on antrum, 221 
ethmoidal, through the orbit, 237 
Gleason's septum, 79 
Goldstein's plastic septum, 103 
Hajek-Luc frontal, 210 
Halle's frontal, 207 
Hazletine's plastic septum, 104 
intranasal frontal, ethmoidal, and 

maxillary, 205, 206, 207, 208, 215 I 
Jansen's, for pansinuitis, 226 ! 

jugular bulb, 835 
Killian's frontal sinus, 213 
Kuhnt-Luc frontal sinus, 212 I 

Kuhnt's frontal sinus, 211 
Kuster's antrum, 222 
Kyle's septum, 84 

Lambert Lack's, for collapse of alse j 
nasi, 283 | 

for larj-ngeal cancer, 532 j 

complete laryngectomy, 539 [ 
endolaryngeal, 532 
laryngofissure, or thyro- 
tomy, 533 I 

partial larjmgectomy, 538 
subhvoid pharvngectomj- 

fof, 537 
th}-rotomy for, 533 
laryngeal stenosis, 479 
bv laryngoscopy, indirect, 521 
Luc-Hajek frontal, 209 
mastoid, in infants and children, 814 
meatomastoid, in chronic mastoiditis, 

802 
membrana tympani, 642, 649 



Operation, Moore's septum, 85 
Mosetig-Moorhof plastic, 838 
Moure's external, on sinus, 236 
for nasal causes of sinuitis, 180 

polypi, 258 
for necrosis and suppuration of 

labyrinth, 815 
Ogston-Luc, 209 
Ollier's external nasal, 268 
for pachymeningitis, circumscribed, 

831 
Passow-Trautmann plastic, 838 
plastic, on facial and hvpoglossal 

nerve, 839, 841 
postauricular fistulse, 836 
Price-Brown septum, 85 
for quinsy, 385 
radical mastoid, 786 
for retropharyngeal abscess, 341 
Roe's septum', 81 
for serous meningitis, 830 
simple mastoid, in acute mastoiditis, 

777 
Sluder's septum, 78 
sphenoidal, 239 
stapedectomy, 707 
for thrombosis of lateral sinus, 831 
tonsil, 393 

author's complete, 396, 403 
Pynchon's cautery dissection, 

"407 
Robertson's, 407 
tracheotomy in diphtheria, 465 
uvula, 339, 340 
Vail's antrum, 217 
Walsham's, for collapse of alaj nasi, 

284 
Watson's septum, 77 
within the vicious circle of nose, 205, 
206, 207 
Opsonic index and vaccine treatment, 127 

129, 399 
Orbito-ethmoidal operation, 237 
Organ of corti, 580 
Orientation, 572 
Orth, 290 

Osier, William, 304, 305 
Ossicles, 572 

spongification of, 705 
Ossiculectomy, 773 

Ostei of posterior ethmoidal cells, 170 
Osteoma of nose, 265 
Osteum maxillare, 169 

sphenoidal, 171 
Ostrum, Louis, 214 

Ostrum's forward cutting antrum forceps, 
220 
localizer for pulley muscle, 214 
Othematoma, 614 
Otitis interna, 851 

media, catarrhal, acute, 670 
chronic moist, 685 

with spongification, 
706 
sequelfp of acute, 711 
suppurative, acute, 70S 



INDEX 



897 



otitis media, suppurative, acute, bacteri- 
ology of, 670, 707 
channels of invasion in, 

671 
etiology of, 708 
in infants and children, 
706 
chronic, 717 

pathology of, 717 
sjTiiptoms of, 717 
parotitica, 855 
OtoHths, 580 
Otosclerosis, 703 
Oval window, 572 

spongification around, 705 
Oxvgen, 19-29 
Ozena, 157, 158 



Pachydermia laryngis, 44, 476 
Pachymeningitis, circumscribed, opera- 
tion for, 831 
externa circumscripta, 759 
internal circumscripta, 761 
Packard, Francis R., 361 
Page, LaFayette, 515 
Panotitis, 854 
Pause, 835 

Papilloma of larynx, 520 
of nose, 261 
of pharynx, 350 
of tonsil, 415 
Paracentesis of membrana tympani, 645 
Paracusis duplex, 866 

in adhesive otitis, 695 
WiUisii, 688, 695 
Paraffin in atrophic rhinitis, 161, 282 
complications following injections of, 

281 
in external deformities of face and 

head, 279 
in nasal dcrniniit ii's, 229 
Paresis of adilurims iriini aneurysm, 501 
Paresthesia of tlic pharvnx, 346 
Parker, C. A., 334, 335 
I'arosmia, 240 
Partial laryngectomy, 538 
Passow-Trautmann oporalion for post- 

auricular fistuhc, 838 
Pathology of actinomycosis, 309 
of acute laryngitis, 426 

plilegmonous lar\ngitis, 432 
rliinitis, 133 
of adenoids, 315 

suppurative otitis media, ()7li 
of adhesive otitis media. 693 
of clironic laryiigitis, I 10 
otitis media, 717 
pliaryugitis, 336 
of glanders, 305 
of iiav fever, 244 
of hyperostosis ..f JMi.vrint li. 701 
of hypertropiiir rliiniii^, 1 i:i 
of laryngeal cancer, .')'Ji> 
57 " 



Pathology of larjmgeal tuberculosis, 292 

of leprosy, 304 

of lingual varix, 333 

of malignant neoplasms of pharvnx, 
354 

of membranous laryngitis, 434 

of nasal polypus, 255 

of otitis media and mastoiditis, 753 

of rhinitis with turgescence, 138 

of rhinoscleroma, 272 

of spongification of labyrinth, 704 

of syphilis of larvnx, 301 

of tubal catarrh," 652 

of tuberculosis of larvnx, 292 
Pean, 531 

Pedro, De Ponce, 772 
Peltesohn, Felix, 313, 314 
Perforation of membrana tvmpani, 640, 
710 
locations and significance 

of, 19 
multiple, 296, 719 
nipple-shaped, 710 
spontaneous, 645 

of septum, 100, 102 
Perichondritis of auricle, 621 
symptoms of, 621 
treatment of, 621 
Perichondrium, adhesion to septal carti- 
lage, 90 
Perilymph, 580 
Peripheral (diplitlieritic) paralysis of the 

pharynx, 348 
Peritonsillitis, quinsy, 383 
Perpendicular plate of etlnnoidal, tlcyia- 

tion of, 73 
Pettit, J. W., 294 
Pharyngeal lacunar tonsillitis, 313 

scissors, 330 
Pharyngitis, catarrlial, 334 

granular, 335 

liyperplastie, 337 

lacimar, 335 

\errucous, 332 
Pharynx, abscess of, 311 

actinomycosis of, 3()S 

akinesis, or paralysis of, 317 

anesllK'sia of, 346 

angii.ma of, 354 

central or l.ulhar paralysis ..f. 3 17 

clironic, 335 

('rnyeilhi<-r's jilexus of. 35 1 

evsKunii of, 351 

.I'iplillMTitic par-alvsis ol. 3 IS 

nhnuiia ..I, 352 

hnielional neuroses of, 3 16 

irniinilar inlhnnnial ion ol, 355 

liypereslh.'sia, 3 16 

liyperlvinesis or spasm of, 317 

lipoma of, 353 

lupus of, 2.S6 

lyniphadenomaof, 351 

lymphoma of, 351 

ni.dfonnjiMoiis of, '^^A 

motor ni'UroKcs of, 347 

neoplasms of, 350 



898 



INDEX 



Pharynx, neoplasms of, nialignant, 354 
neuralgia of, 347 
papilloma of, 350 

paralysis of, complicating facial par- 
■ alysis, 349 

due to bullar disease, 347 
paresthesia of, 346 
sarcoma of, 335 
spasms or liyperkinesis of, 347 
stenosis of, 344 
syphilis of, 299 
teratoma of, 350, 351 
tuberculosis of, 289 
Phillips, Wendell C, 415 
Phlegmonous rhinitis, 274 

tonsillitis and peritonsillitis, 383 
Phonatory functions, the, 17 

spasms, 482 
J'hosphorus in spongification (hyperos- 
tosis), 706 
Phototherapy, Finsen's,' 287 
Physiological law in reference to hearing. 

752 
Physiology of auditory nerye, 580 
of cochlea, 580 
of ear, 577 
of labyrinth, 580 
of perception apparatus, 580 
of Prussak's space, 577 
of Rivinian segment, 577 
of semicircular canal, 580 
of vestibular apparatus, 580 
Pierce, N. H., 97, 141, 669, 724 
Pigeon chest in adenoids, 329 
Pillars of the fauces, 368 
Pilocarpine in adhesiye processes of the 

ear, 698 
Piotrowski, 333 
Pischel, Kasper, 76 
Pischel's dressing, 76 
Plastic surgery of cutaneous meatus, 792 
of facial and hypoglossal nerves, 

839, 841 
of perforation of the septum, 100 
of postauricular fistulse, 837, 838 
Plica supratonsillaris, 386 

triangularis of tonsils, 366 
Pliny, 873 

Pneumomassage of ear, 44, 125, 648, 706 
Politzer, A., 583, 587, 591, 612, 616, 623, 
628, 661, 665, 692, 693, 699, 710, 712, 
718, 728, 732, 733, 795, 846, 847, 848, 
851 
Politzer's acoumeter, 856 
bag, 666 

method of inflation with compressed 
air, 667 
Polypus, aural, 751 
■ cystic, 256 
nasal, 253 

etiology of, 254 
pathology of, 255 
prognosis of, 257 
symptoms of, 256 
treatment of, 257 
of sinuses, 183 



Portals of infection, tonsils as, 360 
Posey, William Campbell, 272, 286 
Postauricular fistula^, operations on, 838 
Posterior ethmoidal sinuses, 170 
Postoperative considerations in cancer of 

larynx, 544 
Poucet, 308 
Poulticing, 123 

Predisposing causes of acute suppurative 
otitis media, 709 
of otitis media, 708 
Pregnant women, tuberculous laryngitis 

in, 296 
Pressure, air, 44 

intranasal, cause of sinuitis, 180 
negative, 18, 22 
Pritchard, Urban, 851 
Probing the frontonasal canal, 195 
Prognosis in acute phlegmonous larvn- 
• gitis, 433 
rhinitis, 134 

suppurative otitis media, 714 
in adenoids, 322 
in cancer of the larynx, 529, 
in cerumen in the meatus, 609 
in chronic pharyngitis, 337 
in fibroma of the pharynx, 353 
in glanders, 307 
in hay fever, 245 
in hypertrophic rhinitis, 144, 151 
in laryngeal tuberculosis, 294 
in laryngitis, 427, 435 
in leprosy, 305 
in nasal polypus, 256 
in othematoma, 615 
in retropharj^ngeal abscess, 341, 342, 

441 
in rhinitis with turgescence, 139 
in spongification (hyperostosis), 706 
in syphilis of larynx, 301 
in tubal catarrh, 653 
in tuberculous laryngitis, 294 

pharyngitis, 290 
in tuberculous otitis media, 298 
Prolapse of ventricle of Morgagni, 477 
Proliferation of tissue or hyperplasia, 18 
Promontory of inner tympanic wall, 574 
] red glow in spongification, 705 

Prout, 489 

Prout's method of recording the watch 
1 test, 586 
Prussak's space, 685 
Pseudocroup, 429 
Pseudodiphtheritic bacilli, 453 
Pseudomembranous croup, 433 
Pyer, 588 
Pynchon, Edwin, 44, 75, 127, 300, 387, 

407, 667, 858 
Pynchon's tonsil hemostat, 401 
operation, 407 



QuENU, 333 

Quincke's luml)ar puncture, 759, 760, 702 



INDEX 



899 



Quins.y, 383 

complications and sequelae, 385 
etiology, 383 
treatment of, 385 



Radiant light, 741 

Radical mastoid operation, 786 

Radiotherapy in lupus of nose, 286 

in sinuitis, 186 

in tuberculosis of larynx, 295 
Radium in laryngeal tuberculosis, 295 
Range of hearing, 587 
Rarefacteur, Delstanche's, 46 

diagnostic value of, 46 
Raugi, 351 

Ray fungus in actinomj^cosis, 309 
Reaction of inflammation, promotion of, 

740 
Reactions of acute inflammation, 105 

of chronic inflammation, 107 
Reault's tonsil punch forceps, 406 
Rebinski, 290 
Rectal alimentation after surgery of 

larynx, 491 
Recurrent laryngeal nerves, complete 
paralj'sis of both, 491 
unilateral paralysis of, 494 
Reed's base line, 827 
Reik, Henry Ottridge, 858 
Reflex neuroses, 241 
Reininger, 157 

Resection of jugular vein, 833 
Resonators, vocal, 504 
Respiratory functions, 17 
Reszke, Jean de, 501, 505 
Retropharyngeal abscess, 341 
Retzius, 5i5 
Reverdin's needle, 812 
Rheumatic paralvsis of auditory nerve, 

865 
Rhinitis, acute, 130-134 

atrophic, 157, 160 

paraffin injections in, 161, 286 

chronic, 137, 157 

witii turgescence, 137 

hyperplastic, 18, 150, 151, 152 

hypertrophic, 142, 143, 144 

mucopurulent, 157 

phlegmonous, 274 

suppurative, 162 

turgescence, 18, 137, 13S, 139 

with collapse of erectile tissue, 156 
liliinorrhea, cerebrospinal, 240 
liiiinoscleroma, 271 
Rliodes' tonsil punch forceps, 10() 
Ribbcrt, 754 

Richards, John, 815, 816, 819, 823 
Ridge of septum, 73 
Rinn('^'s test, 591 
Riverias, 603 

Rivinian segnicnl ;in :il,riinii ui inlccl ion, 
70S 
in cliil.ln'n, 709 



Robertson, C. M., 291, 407 
Robertson's tonsil operation, 407 

scissors, 407 
Roe, 73 
Roe's forceps, 81 

septum operation, 81 
Rontgen rays in lar3^ngeal tuberculos 
295 

in lupus, 287 
Rosenbach, 528 
Roosa, St. John, 733 
Root, A. G., 498 
Roux, 451, 455 
Rumbold, T. F., 585, 586 
Russian perforator, 780, 781 



Saddle nose, paraffin injections in, 279 
Sagging of postsuperior wall of meatus, 

709 
Saissy, 612, 662 
Sarcoma of auricle, 620 
of nose, 267 
of pharynx, 355 
Saw, Fetterolf file, 84 

removal of spurs and ridges with, 74 
Vail's, 217 
Scarification, 123 
Schadle, J. E., 242, 247, 327 
Schleich's solution, 90 
Schmaltz, H., 872, 873 
Schmidt, Moritz, 220, 354, 519, 521 
Schmitzler, 521 
Schrotter, 521, 526 
Schrotter's larjmgeal tubes, 479 
Schwabach test, 191 
Schwalbe, 515 

Schwartze, 661, 669, 732, 877 
Scissors, the Asch, 82 

Holmes' turbinal, 154 
pharyngeal, 330 
Screw-worms in nose, 274 
Secretions, retention of, in acute suppura- 
tive otitis media, IS, 710 
Seifert, 332 
Seigle's otoscope, 128 
Seiss, 332 

Semicircular canals, complete exentera- 
tion of, 817 
function of, 580 
Semon, Sir Felix, 249, 393, 18N, 192, 518, 

520, 525, 527, 529 
Semon's law, 528 
Senator, 489 
Senn, Nicholas, 308 
Sensory, vasomotor, ami nllc\ neuroses, 

241 
Septum, nasal, 17 

Asch-Meyer operation on, si 
cartilaginous deviation of, 71 
choice of operation, 71 
osseous (lo\iations of, 72 
Dcrroralionsof, 100 



900 



INDEX 



Septum, nasal, perforations of, following 
operations, 99 
saw operation on, 74 
soft hypertrophy of, 74 
submiicoiis operation on, 86 
surgical correction of deviations 
of, 74 
Sequela- of acute suppurative otitis media, 
712 
of adenoids, 326 
and complications of acute lacunar 

tonsillitis, 379 
of suppurative otitis media, 731 
of tonsil operations, 411 
Serous meningitis, 759 

operation for, 830 
Serum treatment of hay fe^•er, 249 
Sexton, Samuel, 604 

Shambaugh's hypothesis of sound per- 
ception, 581 
Sheppard, 332, 751 
Shock and sudden death in surgery of 

larynx, 545 
Shrapnell's membrane in acute suppura- 
tive otitis media, 710 
Shurley, E. L., 291 
Siebenmann, 704 

Siebenmann's plastic meatal incision, 798 
Simpson's sponge-tents, 99 
Simulated deafness, 862 

tests for, 863 
Singer's nodules, 444, 475 
Singing voice, defects of, due to improper 

method of breathing, 499, 502 
Sinuitis, 18 

and atrophic rhinitis, 114 

due to, 158 
blindness in, 176 
crust in epipharynx in, 176 
differential diagnosis of, 171 
dizziness in, 166 
ethmoidal surgery of, 232 
exciting causes of, 181 
eye symptoms of, 184 
eyes in relation to, 166 
foreign bodies in nose a cause of, 180 
general etiology, 179 

symptomatology, 184 
Halle's frontal operation, 207 
headache in, 166 
intracranial complications of, 166 
irrigations of, 195, 196, 197, 198, 199 
Jansen's operation for, 226 
kev to, 201 

lavage of, 195, 196, 197, 198, 199 
leukodescent light in treatment of, 

125 
Loeb's projections of, 164 
maxillary, author's operation, 219 
surgery of, 215 
Vail's operation, 217 
multiple, 177 

nasal accessory cause of, 180 
operation cause of, 180 
pressure cause of, 180 
ocular syin|)toms of, 166 



Sinuitis, pathology of, 181 
principles of, 191 
relation to eye, 189 
redness and swelling in diseases of, 

160 
strabismus in, 177 
subjective symptoms of, 188 
svpliilis and tuberculosis as causes of, 
■ 179 
treatment of, 119, 193, 194 

by negative pressure, 199 
Vail's operation on maxillary, 217 
vertigo in, 166 

vicious circle of nose in relation to, 
201 
Sinus tonsillaris, 863 
Sinuses, accessory, 18 

anterior ethmoidal, 167 
empyema of, 171 
exenteration of, difficult, 19 
general consideration, 179 
frontal, 163 

Hajek-Luc, 210, 212 
Killian's operation on, 213 
Kuhnt's operation, 211 
individual, the, 163 
polypi in, 183 
posterior ethmoidal, 170 
series No. I, 163 
No. II, 170 
skiagraphs of, in atrophic rhinitis, 

157 
sphenoid, 171 

surgery of, 163, 201, 204-213 
tenderness upon pressure, 165 
thrombosis of longitudinal and caver- 
nous sinuses, 184 
Skiagraphs, Caldwell's method, 186 
of sinuses, advantage of, 187 
Skiagraphy, 184 

of frontal sinuses, 163 
of sinuses, 157, 160 
Sluder, Greenfield, 71, 78 
Sluder's septum operation, 78 
Smithuison's sphenoidal forceps, 238 
Snydacker, 730 
Solution, Schleich's, 90 
Sondermann, 127 
Sound wa^es, 583 
Spasmodic larvngeal cough or laryngeal 

chorea, 483 
Spasm of adductor muscles, 483 

or hvperkinesis of pharvnx, 347, 349 
of larynx, 482 
of tensor muscle, 483 
Spastic aphonia, 483 
Special sense, disturbances of, in sinuitis, 

189 
Speculum, Allen's nasal, 97 

Ballenger-Foster, 97 
Speech and brain development, 510 

defects of, 510 
Spencer, 724 
Sphenoidal sinus, 171 

operation on, 239 
I Sphcnoiditis, eye symptoms of, 171 



INDEX 



901 



Spine of Henle, 280 ; 

Spokeshave, Chaleway's, 77 

ridges and spurs removed with, 
76 
Si3ongif3dng of bony capsule of labj-rinth, 

703, 706 
Spray tubes, 47, 48 
Stacke, 786 

Stacke-Jansen plastic flap, 800 
Stahl, 611 
Stapedectomy, 707 

in spongification, 706 
Stapes, spongification of, 706 
Steel, J. S., 274 
Stein, O. J., 249, 265, 299, 527 
Stein's alcohol infections in hay fever, 249 
Stenosis, alternating nasal, 17, 137 
of Eustachian tube, 699 
of larynx, 476, 477, 479 
of pharynx, 344, 345 
Stirling, 364, 588 
Stoerk, 545 

Stoerk's blennorrhea, 261 
Stohr, 362 
Strassmann, 360 

Street's tonsil h3'podermic syringe, 397 
Stricture of meatus, 630 
Stucky, J. A., 166, 335, 424, 701, 733 
Subacute mastoiditis, 735 
Subglottic space, neoplasms of, 520 

stenosis of larj-nx, 480 
Subhyoid pharyngotomv, 537 
Subjective noises, 581, 687, 710, 849, 867 
Submucous cauterization, 141 

resection of inferior turbinate, 149 
of septum, 86 
Suker, Geo. F., 700 

Superior laryngeal nerve, parah'sis of, 486 
Suppuration and necrosis of labyrinth, 
815, 856 
nasal, 162 
Suppurative otitis media, acute, 707, 708 
in infants and children, 
716 
chronic, 717 
Siu-gical correction of obstructive lesions 
of nasal septum, 74 
treatment of retropharyngeal abscess, 
331 
of Tli()rii\v:il(!l's dlsi^Lsr, 331 
Surgcrv of acuii m.'i-idiilii i-. 777 
of'BezoM's iM.i.iMi.liii,^, M 1 
of brain nl.Mi--, M' I 
of chronic iM.i-iMhIilis, 802 
of oxtradur.il ;il. -ri-s, S30 
of facial nerve, 811 
paralysis, 841 
of frontal sinus, 204, 2(jr), 20(1, 20(1 
f)f jugular bulb, 835 

vein, 835 
of labyrinth suppuration, 815 
of lateral sinus, 831 
of mastoiditis in infants, 813 
of maxillary sinus, 215 
of ossicles, 772 
of postauricular fistula, 838 



Surger}' of serous meningitis, 830 
of sinuses, 201 
of temporal bone, 772 
Thiersch grafts, 807 
of tonsils, 393 
of uvula, 340 
Sutton, Bland-, 351 
Swain, H. L., 248, 332 
Swivel knife, 92, 94 

antrum, the author's, 320 
mucosa, the author's, 218 
Symptoms of abscess of larynx, 438 

of actinomycosis of pharynx and 

tonsils, 388 
of acute catarrhal pharj-ngitis, 334 
lacunar pharyngeal tonsillitis, 
313 
of adenoids, 318 
of adhesive otitis media, 694 
of atrophic rhinitis, 160 
of catarrhal pharyngitis, 334 
of cerumen in meatus, 608 
of chronic lacunar tonsillitis, 381 
laryngitis, 440 
otitis media, 687 
suppurative, 717 
of diffused inflammation of meatus, 

626 
of edema of the pharynx, 437 
of elongated uvula, 338 
of exostosis of the meatus, 629 
of fibroma of the pharynx, 352 
of foreign bodies in the larynx, 548 
of frostbite of the auricle, 624 
of furunculosis of the meatus, 625 
general, of sinuitis, 184, 187 
of glanders, 306 
of hay fe^•er, 244 
of herpes of the auricle, 622 
of hyperplastic rhinitis, 150 
of hypertrophic rhinitis, 143 
of lacunar inflammation of pharyn- 
geal tonsil, 313 
of laryngitis, 426 
of larj'ngeal cancer, 527 
of membranous laryngitis, 434 
of nasal hydrorrhea, 250 
of ocular in sinuitis, 166 
of otiiematoma, 615 
of otitis media, suppurati\c, (i7(i, (177, 

7()S, 709, 719 
of perforiition of mombraiia 1\in|iani, 
641 
of septum, 101 
of pcriclioiidritis of tlic .•luricic, (121 
(if plilcgiiionous iahvrinthilis, 1:^3 
n\' i.Iionalorv siiiiiilis. 1(1(1 
; i>\ (piiiisy, 3X3 

of rctrn|)liaryiigi'al abscess, 341 
of rhinitis wit.li collapse, 156 

witli lurgcscenco, 13S 
of rliiiiosclcroma, 272 
of spongifyiiig of tlic liouy capsule 

of labvrinth, 705 
of sypIiiUs of larynx, 301 

of nose and pharynx, .'!()0 



902 



INDEX 



n 



Symptoms of tubal catarrh, 653 

of tuberculosis of larynx, pharynx, 
fauces, and tonsils, 289, 293, 
300 
of middle ear and mastoid pro- 
cess, 296 
of uvula, elongated, 338 
Syphilis of labyrinth, 854 

laryngofissure in, 302 
pathology and prognosis of, 301 
of larynx, 30 i, 302 
of nose, fauces, pharynx, and tonsils, 
299 
Syringe, Beck's paraffin, 280 



Tank, accessory compressed-air, 44 

Table or cabinet, treatment, 40 

Tachycardia, nasal, 253 

Talbot, E. S., 612 

Tegmen tjonpani, 579 

Temperature in acute suppurative otitis 

media, 709, 710 
Temporal bone, landmarks of, 576 
Tendency to malignancy, 520 
Teratoma of the pharynx, 351 
Terry, W. J., 528 
Tests of hearing, 583 

principles underlying, 585 • 

for smiulated deafness, 864 
Texas screw-worm, 601 
Thiersch's graft razor, 807 
Thiesen, Clement F., 421, 422 
Thiosinamine in rhinoscleroma, 273 

in adhesive otitis media, 700 
Thompson, .1. S., 327 
Thompson, St. Clair, 251 
Thorner, Max, 288 
Thornwaldt's disease, 313, 330, 331 

author's method of operating, 
331 
Thrombosis of cavernous sinuses, 769 

of jugular bulb, 769 

of lateral sinus, 768 

pathology of, 765, 766 
surgery of, 831 
Thyroid extract in spongification (hyper- 
ostosis). 706 
Tilly, Herbert, 221 
Tinnitus aurium, 581, 687, 710, 849, 

867 
Todd, F., 747 
Tompkins, 422 
Tone blindness, 507 

islands, 581 
Tongue-flap, Gleason's, 80 
Tonsil, absorptive powers of, 361, 367 

actinomycosis of, 308 

anatomy of, 389 

angioma of, 415 

blood supply of, 371 

calculus of, "383 

carcinoma of, 477 

clinical anatomy of, 364 



Tonsil, complete removal of, 406 

complications of operations on the, 

411 
crypts of, 48, 365, 366 
cj^storaa of, 416 
decapitation of, 376 
diseases of, 360 
extirpation of malignant, by external 

route, 418 
fibro-enchondroma of, 416 
fibroma of, 415 
hemorrhage of, 374 
hilus of, 366 

hypertrophy of, 332, 386, 387 
inflammatory diseases of, 376 
knife, the author's, 403 
lingual, 331 
lipoma of, 415 
lymphatics of, 369 
mycosis of, 387 
neoplasms of, 415 
operations on, 395 

author's, 373, 403 
partial removal of, 409 
portals of infection, 360 
pharyngeal acute lacunar inflam- 
mation of, 313 
primary tuberculosis of, 360 
Pynchon's operation, 407 
recurrence of, 374 
Robertson's operation, 407 
I surgery of, 393 

, syphilis of, 299 

syringe, the author's, 414 
Tonsillar artery, 271 
sinus or bed, 368 
Tonsillectomy, author's method, 403 

hospital operation, 414 
Tonsillitis, acute catarrhal lingual, 331 
and chronic lacunar, 377 

bacteriology of, 377 
complications of, 379 
diagnosis of, 379 
etiology of, 377 
pathology of, 378 
sequelae of, 379 
symptoms of, 378, 381 
treatment of, 380, 382 
lacunar pharyngeal, 313 
phlegmonous, 303 
Tonsillotomy, 409 
Toynbee, 694, 854, 872 
Trachea, foreign bodies in, 548 
Tracheobronchoscop3^, position of patient 

in, 552 
Tracheoscopy and bronchoscopy, 551 
Tracheotomy in bilateral abductor par- 
alysis, 498 
in complete paralysis of the recurrent 

laryngeal nerves, 494 
in diphtheria, 465 

after-treatment, 467 
complications, 466 
indications for, 465 
steps of operation, 465 
in edema of the larynx, 437 



INDEX 



903 



Tracheotomy in foreign bodies in larynx 

and tracliea, 549 
Transfusion of gases in air vesicles of 

lungs, 19 
Transillumination of antrum, 173 

of sinuses, 185 
Transudation of serum into submucous 

tissue, 18 
Trautmann, 315 

Treatment of abscess of larj^nx, 438, 439 
of actinomycosis, 310 

of pharynx and tonsils, 309 
of acute catarrhal inflammation of 
lingual tonsil, 331 
lacunar laryngitis, 380, 428 
pharyngeal tonsillitis, 
314 
laryngitis, 120, 428 
otitis media, 119, 681 
pharyngeal tonsillitis, 433 
pharyngitis, 334 
rhinitis, 130, 134 
of adenoids, 322 
of adhesive otitis media, 697 
of angioma of pharynx, 354 
of animate foreign bodies in ear, 605 
of asthma, 252 
of atrophic laryngitis, 446 

rhinitis, 160 
Bier's, 118, 126 
indications for, 128 
cabinet or table, 40 
of cancer of larynx, 532 
of catarrhal pharyngitis, 334 

sinuitis, 193 
of cerumen in meatus, 609 
of chronic inflammation, 121 
lacunar tonsillitis, 382 
laryngitis, 441 
otitis media, 690 
pharyngitis, 337 
rhinitis with collapse of erectile 

tissue, 157 
suppurative otitis media and 
mastoiditis, 744, 745 
sinuitis, 194 
of croupous inflammation of meatus, 

628 
of cystoma of pharynx, 351 
of cysts of auricle, 618 
of dermatitis of auricle, 618 
of diffused inflammation of meatus, 

627 
of diphtheria, 459, 462 
of eczema of ear, 634 
of edema of larynx, 437 
of elongated uvula, 339 
of epistaxis, 270 
of exostosis of meatus, 629 
of facial paralysis, 840 
of flbroma in the larynx, 449 

of pharynx, 353 
of foreign bodies in ear, 601, 605 
of furunculosis of meatus, 626 
of glanders, 307 
of hav fever, 216 



Treatment of hemorrhagic laryngitis, 447 
of herpes of auricle, 622 

zoster of auricle, 623 
of hyperplastic rhinitis, 152 
of hypertrophic rhinitis, 144 
of keratosis obturans, 610 
of laryngeal chorea, 484 
cough, 484 
tuberculosis, 294 
of laryngismus stridulus, 483 
of lingual varix, 333 
of lupus of auricle, 287 
of malformations of pharynx, 345 
medicinal, of acute rhinitis, 137 
of membranous laryngitis, 435 
of nasal polypus, 257 
by negative air pressure, 127, 199 
of neuralgia of pharynx, 347 
opsonic index and Koch's new tuber- 
culin, 129 
of othematoma, 615 
of papilloma of pharynx, 350 
of perforation of membrana tympani, 
642 
of septum, 102 
of perichondritis of auricle, 621 
of phonatory spasms, 484 ' 
of quinsy, 385 

of retropharyngeal abscess, 341, 342 
of rhinitis with turgescence, 139 
of rhinoscleroma, 273 
serum, of hay fever, 249 
of sinuitis, 119 

principles of, 191 
of spongifying of labyrinth, 706 
of stenosis of pharynx, 345 
of stricture of meatus, 630 
of syphilis of larynx, 302 
table or cabinet, 40 
of teratoma of pharynx, 351 
of tone blindness, 507 
trypsin, of malignant neoplasms, 356 
of tubal catarrh, 653 
of tuberculosis of larynx, 294 

of middle ear and mastoid pro- 
cess, 298 
of pharynx and fauces, 290 
of tuberculous otitis media, 298 
Trephine for brain abscess, 826 
Trigeminus, pressure on branches of, a 

cause of headache, 38 
Trousseau, 465 

Trypsin treatment of malignant neo- 
plasms, 356, 357 
Tubal catarrh, 652 
Tube, auscultation, 663 
Tuberculous laryngitis, 290 
diagnosis of. 293 

by inoculation of guiiicii- 
pigs, 2SS 
etiology of, 293 
pathology of, 290 
in pregnant women, '2'M\ 
prognosis of, 294 
symptoms of, 293 
treatment of, 294 



904 



IXDEX 



Tuberculous larvngitis, treatment of 
Tooper Hewitt light, 295 
curettage, 295 
formaldehyde, 294 
leukodescent light, 295 
radiotherapy, 295 
otitis media, 296 

formaldehyde treatment of, 
299 
pharyngitis, 289, 290 
rhinitis, 287 

treatment, 289 

Finsen light, 289 
leukodescent, 289 
stenosis of larynx, 479 
tonsillitis, 360 
Tubes, DeVilbiss' spray, 44 
Turbinal engorgement, 18 

influence of, on respiration, 17 
obstruction due to, 115 
middle, pressure of, a cause of 
asthenopia, 38 
Turbinated bone, inferior, submucous 
resection of, 149 
bodies, 19 

erectile tissue of, 19 
heating and humidifying appa- 
ratus of, 19 
inferior, 19 
middle, 19 

regulators of nasal secretions, 19 
superior, 19 

supply secretion for lower respi- 
ratory tract, 19 
swell bodies of, 19 
vasomotor nerves, regulators of, 
19 
Turbinectomy, hemorrhage after, 156 
with author's knives, 231 
swivel knife, 155 
Tiirck, 296 

Turgescent rhinitis, 137 
Turner, Logan, 315, 316, 319, 320 
Tympanic cavity, physiology of, 578 
Tympanum, walls of, 573 



U-SHAPED incision, Gleason's, 80 
Uncinate cells, obstruction due to, 115 
Urbantschitsch, 605, 878 
Upper tracheoiironchoscopy, 558 
after-treatment, 564 
anesthesia in, 559 
introducing split-tube spatula, 
560 
tracheobronchoscope, 560 
position of head of patient, 559 
preparation of patient, 558 
removal of foreign body by, 561 
of secretions and blood, 561 
Uvula, edema of, 337 
elastic, 339 
elongated, 338 
treatment of, 340 



Vaccine and opsonic imlex treatment, 

128 
Vail, D. T., 217 
Vail's antrum saw, 217, 223 

operation, 217 
Valsalva's method of inflation, 661 
Varix, lingual, 332 

Veins, varicose, at base of tongue, 332 
Ventricle of Morgagni, prolapse of, 477 
Verneuil, 333 
Vertigo in sinuitis, 166 
Vesicles, the air, 19 
Vestibular apparatus, function of, 580 
Vestibule of labyrinth, operation on, 820 
Bourguet's method, 820 
of the nose, 18 
Vibratory massage of the Eustachian 

tube, 668 
Vicious circle of nose, 19, 201 
Vienna paste in tuberculosis of nose, 28S 
Vieussens, 157 
Villar, 352 
Virchner, 352 
Virchow, 416, 526, 612 
Vocal resonators, 504 

factors which influence, 503 
'X^oice after laryngectomy, 546 

singing, 499 
Voices and music, hearing of, 869 
Volkmann's osteitis vascularis chronica, 

705 
Voltolini, 607, 850, 851, 852 
Vomer, the author's method of removing, 

88,94 
Von Babes, 362 
Von Bergmann, 527 
Von Esmarch, 262 
Von Langenbeck, 262 
Von Troltsch, 605, 694, 727, 872 



W 



Wade, 357 

Waldeyer's ring, 321 

Wales, Ernest de Wolfe, 575 

Walsham, 284, 362 

Walsham's operation for collapse of air 

nasi, 284 
Water basin, hot-, 41 
Watson, A. W., 71, 77 
Watson, Spencer, 253 
Waxham, F. E., 468 . 
Weaver, 658 
Weber, O., 264 
Weber's experiment, 589 

test in acute otitis metlia, 710 
Webs of the larynx, 478 
Weeden, 609 
Weichselbaum, 754 
Weickmeister, 530 
Weiss, 717 
Welch, Wm. H., 448 
Wells, Walter, A., 220 



INDEX 



905 



Wells' antrum perforator and rasp file, 

220 
Wet cupping, 123 
AMiiting, Fredrick, 476, 477, 733, 777, 778, 

78 1, 829, 831 
^Miiting's encephaloscope, 829 
Wilde, 777, 872 

Williams, Watson, 253, 361, 362, 443, 447 
Williston, 601 
Wilson, N. L., 393, 496 
Wines, 880 

Wingrave, Wyatt, 757 
Wippern, A. G., 262 
Woakes, 424 
Wolff, Oscar, 586, 587 
Wood, C. A., 166 
AA'ood, George B., 387, 389, 406 
Word-deafness or sensory aphasia, 870 



Worms, screw-, in the nose, 274 
Wright, Jonathan, 48, 127, 128, 272, 286, 
362, 367, 377, 518, 521 



Yellow kid or lop ear, 611 
Yersin, 451 



Zachias, 872 

Zaufal, 311, 602, 670, 719, 720 
Ziem, 166, 190, 191 
Ziemssen, 349, 525 
Ziickerkandl, 333 
Zwaardemaker, 588 



I 



kv 



"^^(^^ 



